This definition is provided for illustrative purposes only. Consult the applicable health benefit plan contract (member's Evidence of Coverage) for the specific definition of investigational or experimental.
Investigational or experimental is used to describe a service (a medication, biological product, device, equipment, medical treatment, therapy, or procedure) that Health Net has determined is not presently recognized as standard medical care for a medically diagnosed condition, illness, disease, or injury.
A service is considered experimental or investigational if it meets any of the following criteria:
- It is currently the subject of an active and credible evaluation (such as clinical trial or research) to determine:
- Clinical efficacy
- Therapeutic value of beneficial effects on health outcomes
- Benefits beyond any established medical based alternatives
- It does not have final clearance from applicable government regulatory bodies, such as the United States Food and Drug Administration (FDA), and unrestricted market approval for use in the treatment of a specified medical condition of the condition for which authorization of the service is requested and is the subject of an active and credible evaluation
- The most recent peer-reviewed scientific studies published or accepted for publication by nationally recognized medical journals do not conclude, or are inconclusive in finding, that the service is safe and effective for the treatment of the condition for which authorization of the service is requested