Defining Experimental Therapy — A Third-Party Payer's Dilemma

Abstract

Most health insurers exclude "experimental" or unapproved therapies\nfrom coverage, yet when patients challenge denial of coverage in the courts,\ninsurers often are ordered to pay for such treatments on the grounds that\ntheir definitions of what is experimental are ambiguous. Costs are forcing\nhealth insurers to respond to the problem of how to define experimental\ntherapies in ways that are legally defensible, understandable to the\npurchasers of policies, and flexible enough to cover all disciplines of\nmedicine. Newcomer examines the implications for patients and for medicine of\nseveral options for solving the dilemma: a) listing specific exclusions in the\ninsurance policy; b) defining the criteria for experimental therapy in the\npolicy document; c) allowing coverage only if the patient enters a randomized\ntrial for experimental treatment; d) making coverage decisions on a\ncase-by-case basis; and e) offering optional riders to the policy. (KIE\nabstract)