PBH provides an external, independent review process to review
its coverage decisions regarding experimental or investigational
therapies for members who meet all of the following criteria:
1) The member has a Life-threatening or Seriously debilitating
condition, as defined below and which meet the criteria
listed in items #2, #3, #4 and #5 below:
- "Life-threatening" means either or both of
the following: (i) diseases or conditions where the likelihood
of death is high unless the course of the disease is interrupted;
(ii) diseases or conditions with potentially fatal outcomes,
where the end point of clinical intervention is survival.
- "Seriously debilitating" means diseases or
conditions that cause major irreversible morbidity.
2) You have certified that the member has a Life-threatening
or Seriously debilitating condition, as defined above, for
which standard therapies have not been effective in improving
the condition, or for which standard therapies would not
be medically appropriate, or for which there is no more
beneficial standard therapy covered by PBHC than the therapy
proposed pursuant to paragraph (3); and
3) You have recommended a treatment, drug, device, procedure
or other therapy, certified in writing with a statement
of evidence, that is likely to be more beneficial than any
available standard therapies; and
4) A PBH Medical Director or designee has denied your request
for a drug, device, procedure or other therapy recommended
or requested pursuant to paragraph (3); and
5) The treatment, drug, device, procedure or other therapy
recommended would be a covered service, except for PBH's
determination that the treatment, drug, device, procedure
or other therapy is experimental or investigational.
PBHC's external, independent review for experimental and
investigational treatment will be provided as outlined under
the Voluntary Independent External Review (VIER) Program.
