External Review of Experimental or Investigational Treatment Adverse

External Review of Experimental or Investigational Treatment Adverse Determinations A. 1. Within four (4) months after the date of receipt of a notice of an adverse determination or final adverse determination pursuant to Rule 15.04 of this Regulation that involves a denial of coverage based on a determination that the health care service or treatment recommended or requested is experimental or investigational, a covered person or the covered person’s authorized representative may file a request for external review with the Commissioner. 2. a. A covered person or the covered person’s authorized representative may make an oral request for an expedited external review of the adverse determination or final adverse determination pursuant to paragraph (1) if the covered person’s treating physician certifies, in writing, that the recommended or requested health care service or treatment that is the subject of the request would be significantly less effective if not promptly initiated. b. Upon receipt of a request for an expedited external review, the Commissioner immediately shall notify the health carrier. c. i. Upon notice of the request for expedited external review, the health carrier immediately shall determine whether the request meets the reviewability requirements of subsection B. The health carrier shall immediately notify the Commissioner and the covered person and, if applicable, the covered person’s authorized representative of its eligibility determination. ii. The Commissioner may specify the form for the health carrier’s notice of initial determination under item (i) and any supporting information to be included in the notice. iii. The notice of initial determination under item (i) shall include a statement informing the covered person and, if applicable, the covered person’s authorized representative that a health carrier’s initial determination that the external review request is ineligible for review may be appealed to the Commissioner. d. i. The Commissioner may determine that a request is eligible for external review under subsection B(2) notwithstanding a health carrier’s initial determination the request is ineligible and require that it be referred for external review. ii. In making a determination under item (i), the Commissioner’s decision shall be made in accordance with the terms of the covered person’s health benefit plan and shall be subject to all applicable provisions of this Regulation. e. Upon receipt of the notice that the expedited external review request meets the reviewability requirements of subsection B(2), the Commissioner immediately shall assign an independent review organization to review the expedited request from the list of approved independent review organizations compiled and maintained by the Commissioner pursuant to Rule 15.11 of this Regulation and notify the health carrier of the name of the assigned independent review organization. f. At the time the health carrier receives the notice of the assigned independent review organization pursuant to subparagraph (e) of this paragraph, the health carrier or its designee utilization review organization shall provide or transmit all necessary documents and information considered in making the adverse determination or final adverse determination to the assigned independent review organization electronically or by telephone or facsimile or any other available expeditious method. B. 1. Except for a request for an expedited external review made pursuant to subsection A(2), within one (1) business day after the date of receipt of the request, the Commissioner receives a request for an external review, the Commissioner shall notify the health carrier. 2. Within five (5) business days following the date of receipt of the notice sent pursuant to paragraph (1), the health carrier shall conduct and complete a preliminary review of the request to determine whether: a. The individual is or was a covered person in the health benefit plan at the time the health care service or treatment was recommended or requested or, in the case of a retrospective review, was a covered person in the health benefit plan at the time the health care service or treatment was provided; b. The recommended or requested health care service or treatment that is the subject of the adverse determination or final adverse determination: i. Is a covered benefit under the covered person’s health benefit plan except for the health carrier’s determination that the service or treatment is experimental or investigational for a particular medical condition; and ii. Is not explicitly listed as an excluded benefit under the covered person’s health benefit plan with the health carrier; c. The covered person’s treating physician has certified that one of the following situations is applicable: i. Standard health care services or treatments have not been effective in improving the condition of the covered person; ii. Standard health care services or treatments are not medically appropriate for the covered person; or iii. There is no available standard health care service or treatment covered by the health carrier that is more beneficial than the recommended or requested health care service or treatment described in subparagraph (d) of this paragraph; d. The covered person’s treating physician: i. Has recommended a health care service or treatment that the physician certifies, in writing, is likely to be more beneficial to the covered person, in the physician’s opinion, than any available standard health care services or treatments; or ii. Who is a licensed, board certified or board eligible physician qualified to practice in the area of medicine appropriate to treat the covered person’s condition, has certified in writing that scientifically valid studies using accepted protocols demonstrate that the health care service or treatment requested by the covered person that is the subject of the adverse determination or final adverse determination is likely to be more beneficial to the covered person than any available standard health care services or treatments; e. The covered person has exhausted the health carrier’s internal grievance process unless the covered person is not required to exhaust the health carrier’s internal grievance process pursuant to