Investigational and Experimental Treatment

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

Medi-Cal indicates:

  1. Experimental services are not covered.
  2. Investigational services are not covered except when it is clearly documented that all of the following apply:
    1. Conventional therapy does not adequately treat the intended patient's condition.
    2. Conventional therapy does not prevent progressive disability or premature death.
    3. The provider of the proposed service has a record of safety and success with the investigational service equivalent or superior to that of other providers of the service.
    4. The investigational service is the lowest cost item or service that meets the patient's medical needs and is less costly than all conventional alternatives.
    5. The service is not being performed as a part of a research study protocol.
    6. There is a reasonable expectation that the investigational service significantly prolongs the intended patient's life or maintains or restores a range of physical and social function suited to activities of daily living.

    All investigational services require prior authorization. Payment is not authorized for investigational services that do not meet the above criteria, or for associated inpatient care when a member needs to be in the hospital primarily because she or he is receiving such non-approved investigational services.

PPG Responsibilities

PPGs must immediately forward all pertinent documentation for investigational or experimental treatment service requests via fax to the Health Net Medi-Cal Health Services Department. Health Net's Medi-Cal Health Services Department has a dedicated fax number to receive and process prior authorization requests.