Ok, so I read the Insurance Warrior's book and was looking at my definition for what will probably come with my denial (I work for my insurance compnany
)
It will be denied experimental and investigational so according to my plan it has this definition:
Experimental, investigational or for research purposes
:
means a drug, biological product, device,
treatment or procedure that meets any one of the following criteria as determined by the
Plan Manager:
1. Is identified as not covered by the Health Care Finance Administration Medicare Coverage Issues
Manual as experimental;
2. Cannot be lawfully marketed without the final approval of the United States Food and Drug
Administration (FDA) and which lacks such final FDA approval for the use or proposed use, unless
1) it is found to be accepted for that use in the most recently published edition of the United States
Pharmacopeia-Drug Information for Healthcare Professionals (USP-DI) or in the American Hospital
Formulary Service (AHFS) Drug information, or 2) it is identified as widely used and generally
accepted as effective for the proposed use as reported in a national database of peer reviewed medical
literature published in the English language as of the date of service;
3. Is a device required to receive Premarket Approval (PMA) or 510K approval by the FDA but has not
received a PMA or 510K approval;
4. Is not identified as widely used and generally accepted as effective for the proposed use as reported in
a national database of peer reviewed medical literature published in the English language as of the
date of service; or
5. Is subject of a Phase I trial or is otherwise under study to determine its maximum tolerated dose, its
toxicity, or its safety.
I will address each one and tell me what you think...
1. Medicare has only addressed the issue for those over 60, right? so this does not pertain to me since I am 30.
2.N/A - FDA approved
3. N/A
4. I just need to get some peer reviewed articles, right? What has everyone else used? What is suggested?
5. N/A