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How does my insurer decide what is an experimental treatment?

There is little consistency among managed care organizations in determining which treatments are considered “experimental” and, therefore, excluded from coverage.  What is deemed “experimental” by one plan may be standard to another.  Therefore, many insurers look to Medicare to design their coverage.

Medicare bases its coverage amounts on whether or not the services are “reasonable and necessary.”  “Reasonable and necessary” services are defined as services that are “safe, effective, appropriate, and not experimental.” This may include massage, bodywork, and other alternative treatments.  On the private side, some insurers have developed an objective process for determining whether a technology is no longer to be considered “experimental.” Guidelines include: 

• The technology must have final approval from the appropriate
  government regulatory bodies
• Scientific evidence allows conclusions related to alternative medicine
  therapies effect on health outcomes
• The alternative medicine therapy must improve health outcomes; and
• These improvements must be achievable outside the research setting.

While most health plans and insurers have traditionally relied on scientific or medicine research studies to determine whether an alternative medicine therapy will be covered, an increasing number now require approval from a medical association and/or an independent board of physicians to provide coverage for an experimental treatment.

Miracle Touch: A Complete Guide to Hands-On Therapies That Have the Amazing Ability to Heal

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Miracle Touch: A Complete Guide to Hands-On Therapies That Have the Amazing Ability to Heal

Discover the Healing Power of Human TouchCurious about the benefits of touch therapy? Interest in hands-on therapies has skyrocketed, and even conventional physicians now embrace these treatments as...

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Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.