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Guidelines on Investigational or Experimental Procedures

You are not covered for a service, supply, device, or drug that is deemed investigational or experimental. A treatment is considered investigational or experimental when it has progressed to limited human application, but has not achieved recognition as being proven effective in clinical medicine.

 

To determine investigational or experimental status, we may refer to the technical criteria established by the Blue Cross and Blue Shield Association, including whether a service, supply, device, or drug meets these criteria:

  • It has final approval from the appropriate governmental regulatory bodies.
  • The scientific evidence must permit conclusions concerning its effect on health outcomes.
  • It improves the net health outcome.
  • It is as beneficial as any established alternatives.
  • The health improvement is attainable outside the investigational setting.

These criteria are considered by the Blue Cross and Blue Shield Association's Medical Advisory Panel for consideration by all Blue Cross and Blue Shield member organizations. While we may rely on these criteria, the final decision remains at the discretion of our Medical Director, whose decision may include reference to, but is not controlled by, policies or decisions of other Blue Cross and Blue Shield member organizations. You may access our medical policies here on Wellmark.com.

If you receive services that are deemed investigational or experimental, you are responsible for the cost if:

  • You receive the services from a nonparticipating provider; or
  • You receive the services from a PPO, Network or participating provider in the Wellmark service area and:
    • The provider informs you in writing before rendering the services that Wellmark determined the services to be investigational or experimental; and
    • The provider gives you a written estimate of the cost for such services and you agree in writing, before receiving the services, to assume the payment responsibility. If you do not receive such a written notice, and do not agree in writing to assume the payment responsibility for services that Wellmark determined to be investigational or experimental, the PPO, Network or participating provider is responsible for these amounts.
  • You are also responsible for the cost if you receive services from a provider outside of the Wellmark service area or Network that Wellmark determines to be investigational or experimental. This is true even if the provider does not give you any written notice before the services are rendered.

 

 


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