SSMC Employee Health Benefit Plan
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INVESTIGATIVE OR EXPERIMENTAL - Any care that is not widely accepted professionally in the
United States as effective, appropriate and essential treatment of a reported Illness or Injury based upon
recognized standards of health care in effect at the time Services or Supplies were Incurred. A drug, device,
medical treatment or procedure is Investigative or Experimental if:
1. The drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug
Administration (FDA) and approval for marketing has not been given at the time the drug or device is
furnished or an FDA approved drug or device is used for purposes other than those conditions for which
approved;
2. Reliable evidence shows that the drug, device or medical treatment or procedure is the subject of ongoing
Phase I, II or III clinical trials or under study to decide its maximum tolerated dose, its toxicity, its safety,
its efficacy, or its efficacy as compar ed with the standard means of treatment or diagnosis; or
3. Reliable evidence shows that the consensus among experts regarding the drug, device or medical
treatment or procedure is that further studies or clinical trials are necessary to determine its maximum
tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of
treatment or diagnosis;
4. Reliable evidence shows that the consensus among experts is that the drug, device or medical treatment
or procedure once recognized as effective is no longer considered effective treatment for the condition;
5. The Centers for Medicare & Medicaid Services (CMS) coverage criteria are not met for the drug, device
or medical treatment or procedure; or
6. The Claim Administrator decides that the treatment, procedure, device, drug or medicine is Investigative
based on the above rules.
Reliable evidence shall mean only published reports and articles in the authoritative medical and scientific
literature; the written protocol or protocols used by the treatment facility or the protocol(s) of another facility
studying substantially the same drug, device or medical treatment or procedure; or the written informed
consent used by the treating facility or by another facility studying substantially the same drug, device or
medical treatment or procedure. If any of the entities used to determine the Investigative status of a drug,
device, supply, treatment or any other medical service reverses, modifies, or establishes its policy for such
expenses, and makes such changes retroactive, the Plan will not make payment for related retroactive
Incurred Expenses. The Plan will not seek refund for its previous payments, nor make payments for any
previously denied expenses, affected by such retroactive changes.
LATE ENTRANT - An eligible Employee or Eligible Dependent who is enrolled for Plan coverage more
than 31 days after initial eligibility.
LEGAL SPOUSE - See Spouse
LIFETIME - Any reference to Lifetime shown in this Plan means all periods during which the person is
Covered under the Plan. Under no circumstances, does the Plan pay benefits for any period during which the
person does not meet Plan eligibility or continuation requirements.
MAINTENANCE CARE - Care rendered and directed at relieving discomfort or preserving function
secondary to conditions where further enhancement of function cannot be demonstrated or expected. Care
that cannot be reasonably expected to lessen the patient's disability enabling him or her to leave an institution.
Maintenance Care does not imply the absence of symptoms nor does it imply such services are not necessary.
It implies care rendered to maintain a function and prevent the condition from worsening.
MEDICALLY NECESSARY OR MEDICAL NECESSITY - Services, drugs, Supplies or equipment
provided to a patient for the treatment of an Illness or Injury, only when it meets all of the following
requirements:
1. It is consistent with the symptom or diagnosis and treatment of the sickness, disease, ailment or Injury;
2. It is according to generally accepted standards of good medical practice in the USA at the time expenses
Incurred;
