Criteria for decision-making in Experimental or Investigational IMRs

The three reviewers assigned to determine whether a denial in an experimental/investigational IMR should be upheld or overturned are to assess and describe:

1. the reasons the requested therapy is or is not likely to be more beneficial for the enrollee than any available standard therapy and



2. the reasons that the expert recommends that the therapy should or should not be provided by the plan, citing the enrollee's specific medical condition, the relevant documents provided, and the relevant medical and scientific evidence.

The reviewers may justify their determination on a number of different types of medical and scientific evidence, including peer-reviewed studies and journals, standard medical reference materials and findings, studies, or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes.