- Item or service required to sustain life
- Item or service would substantially improve the quality of life for a terminally ill patient
- Item or service is necessary as a replacement due to a violence of nature
- Item or service is necessary to prevent a higher level of care
The services requested must meet medical necessity criteria and must be prior authorized by the Medical Director. These exceptions will be time-limited, and will be made on a case-by-case basis. In no event will the decision on an individual case be construed to set precedent for future cases. Since these decisions are exceptions to the standard benefits, no appeal process is available.
Member’s PCP must inform the Company of their desire for an exception. Any requests that do not meet the policy guidelines listed above will be denied.
The request must be accompanied by medical records documenting the current status and treatment outcomes, the two proposed treatment plans if appropriate, (one through covered benefits available and one through non-covered benefits available), and the time frames and outcomes expected for the different options.
Both options will be evaluated for cost-benefit and a final exception decision will be made by the Medical Director based on the specifics of the individual case.
Since these decisions are exceptions to the coverage standards, no appeal process is available.