Los Angeles Anthem Denials of Experimental/Investigational Treatments Lawyer

Anthem’s denial of a claim based on their assertion that a treatment is experimental or investigational and is therefore excluded from your policy can have several consequences for both you and your healthcare provider. Foremost of them all, you may lose an opportunity to pursue a treatment recommended by your doctor when all other treatment options are exhausted.

You may be feeling confused, frustrated, and hopeless in such a situation. However, you do have legal rights, and those rights provide you with options. If you were recently denied coverage for your claim, you may want to consult with a Los Angeles Anthem denials of experimental/investigational treatments lawyer to learn more about what you could do next.

What are Experimental/Investigational Treatments?

For some medical conditions, doctors may suggest or prescribe treatment that is considered by a health insurance company to be investigational or experimental. In general, health insurance companies have policy exclusions for treatments they consider to be in this category, citing lack of proof that these treatments are safe and effective for their intended use to make them an uncovered benefit of the policy.

Anthem Blue Cross defines “experimental or investigational” as any treatment, therapy, procedure, drug or drug usage for non-FDA-approved reasons, facility, equipment, device usage, or supplies that are not generally recognized as being medically safe and effective for use in the treatment of an illness, injury, or condition at issue.

Experimental/Investigational Treatments under California Law

California insurance laws require examining the following factors when it comes to making the determination that a treatment is experimental or investigational:

  • The policy’s language surrounding exclusions
  • The Standard of Review
  • The degree of acceptance of the treatment within the medical community

However, California Insurance Code §10145.3 and Health & Safety Code §1370.4 (the Friedman-Knowles Act) mandates that insurance companies cover experimental treatment that would be excluded from the plan under normal circumstances if an independent medical review shows that the treatment would be more advantageous than other conventional treatments.

Additionally, California Health and Safety Code §1367.21 requires that insurance companies cover off-label use of FDA-approved drugs when the treatment meets certain standards. However, many companies—Anthem included—often attempt to deny coverage for these drugs if one is being used for a purpose for which it has not been directly approved by the FDA.

An Anthem denials of experimental/investigational treatments lawyer in Los Angeles should be familiar with these laws and how they apply in different circumstances, which could make them an outstanding resource for claimants whose coverage requests were denied.

Let a Los Angeles Anthem Denials of Experimental/Investigational Treatments Attorney Help

When it comes to your health, you should stand up for your rights and seek out those who would do the same. An experienced insurance attorney could make it their goal to help you in this endeavor.

A Los Angeles Anthem denials of experimental/investigational treatments lawyer could evaluate the circumstances of your case and present you with a legal game plan moving forward. This may include filing an appeal—or even a second appeal—with Anthem, seeking the opinion of an independent medical party, or even taking your case to court. Call today to stand up for your rights when it comes to your Anthem health coverage.