Types of IMRs – Services considered
Experimental or Investigational

A plan may deny requested health care services when it considers the treatment, medication or services to be experimental or investigational. Such denials may be submitted to IMR if the following conditions are met:

1. The enrollee has a life threatening or seriously debilitating disease or medical condition. Life threatening means either conditions where the likelihood of death is high unless the course of the disease is interrupted or conditions with potentially fatal outcomes where the end point of clinical intervention is survival. Seriously debilitating means diseases or conditions that cause major irreversible morbidity.



2. A request for services was denied by the plan or medical group based on a finding that it is experimental or investigational;


and


3. A certification is provided from a treating or supporting physician.

Applicants are not required to submit a grievance to the health plan before applying for an experimental/investigational IMR.