California Code of Regulations
Title 28 - Managed Health Care
Division 1 - The Department of Managed Health Care
Chapter 2 - Health Care Service Plans
Article 8 - Self-Policing Procedures
Section 1300.70.4 - Independent Medical Reviews Experimental and Investigational Therapies
Current through Register 2024 Notice Reg. No. 12, March 22, 2024
(a) Enrollees of a health care service plan may request an independent medical review pursuant to sections 1370.4, 1374.30 through 1374.34 of the Act and section 1300.74.30 of title 28 when the plan has denied a therapy or medical service that would otherwise be covered based on the plan's determination that the therapy or medical service is experimental or investigational. This eligibility also applies to Medicare enrollees to the extent it does not conflict with federal law.
(b) At the time of the plan's denial of coverage for experimental or investigational therapy, or denial of urgent care or emergency services, as defined in section 1300.67(g)(2), the plan shall notify the enrollee of the ability to seek independent medical review.
(c) Included with the enrollee's application to the Department for independent medical review shall be a copy of the plan or contracted provider's written denial of the therapy or medical service based on the determination that the therapy or service is experimental or investigational.
(d) A certification from the enrollee's treating physician shall be included with the application for independent medical review. The physician's certification shall be on a form from the Department entitled, "Physician Certification Experimental/ Investigational Denials" (DMHC/IMR 110-11/27/00), or contain all of the following information:
(e) Incomplete applications will not be referred to an independent medical review organization. However, the Department may waive this requirement in exceptional or compelling circumstances where the need for a prompt determination precludes obtaining all information in writing. In cases accepted for an urgent review, the enrollee's physician must certify in writing, at a minimum, that the enrollee has a life-threatening or seriously debilitating condition, as defined in Health and Safety Code section 1370.4(a), that the requested therapy is likely to be more beneficial to the enrollee than any available standard therapy and describe the medical and scientific evidence relied upon in making the recommendation.
1. New
section filed 11-12-2002; operative 12-12-2002 (Register 2002, No.
46).
2. Amendment of subsections (a) and (b) filed 6-17-2005;
operative 7-17-2005 (Register 2005, No. 24).
Note: Authority cited: Section 1344, Health and Safety Code. Reference: Section 1370.4, Health and Safety Code.