Investigational Procedures Or Treatments

The Department may cover investigational procedures or treatments on a case-by-case basis for life-threatening conditions when no other treatment options are available. For these cases, a focused case review is completed by the Department. The Department will determine coverage based on this review. (7-1-26) 01. Focused Case Review. A focused case review consists of assessment of: (7-1-26) a. Health benefit to the participant; (7-1-26) b. Risk to the participant; (7-1-26) c. Standard treatment for the participant’s condition, including alternative treatments; (7-1-26) d. Specific inclusion or exclusion by Medicare national coverage guidelines; (7-1-26) e. Phase of the clinical trial of the proposed procedure or treatment; (7-1-26) f. Guidance regarding the proposed procedure or treatment by national organizations; (7-1-26) g. Pertinent clinical data and peer-reviewed literature; and (7-1-26) h. Ethics Committee review, if appropriate. (7-1-26) 02. Additional Clinical Information. If there is insufficient information from the focused case review to render a coverage decision, the Department may seek an independent professional opinion. (7-1-26) 062. – 069. (RESERVED) MEDICAID BASIC PLAN COVERED SERVICES (Sections 070-449) SUB AREA: HOSPITAL SERVICES (Sections 070-089)