Investigational Treatment Many insurers will deny claims deemed to be investigational (experimental), unnecessary or inappropriate. Bone marrow transplants and certain other new treatments often fall into this category. While there is no guaranteed way to prevent denial of such a claim, make sure you attempt to receive pre-approval for the treatment from your insurance carrier in writing. To do this, you should have a letter of medical necessity from your physician documenting that the proposed treatment is medically appropriate, along with supporting clinical literature and a full description of the procedure or services to be provided. The anticipated cost and duration of the treatment should also be included.
Off-Label Treatment Your insurer may deny a claim if the drug your doctor has prescribed is used for other than its labeled indication or the use listed on the drug company's "package insert." The claim may also be denied if the drug is used in a new dosage, according to a new schedule, given by a different route or combined with other drugs.
You should be aware that fully half of all uses of cancer drugs are not those listed on the official package insert or label. Such use reflects advances in cancer treatment that occurred after the drug was released onto the market and are in fact the ordinary, proper and accepted uses of such drugs. Not to use certain drugs for established "off-label" uses may be inappropriate.
When there is a denial of payment for a claim because the use of the drug was "off-label," it is very important that this be appealed to the insurance carrier. These denials are usually reversed, especially if the use of the drug
