Free Appeal for “Experimental or Investigational” Denials

The insurer classified the treatment as experimental or investigational and therefore not covered. Treatments with FDA approval or inclusion in clinical guidelines are generally not experimental.

45%
Appeal Success Rate
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How to Appeal “Experimental or Investigational” Denials

When your insurer denies a claim as “experimental or investigational,” it means the insurer classified the treatment as experimental or investigational and therefore not covered. treatments with fda approval or inclusion in clinical guidelines are generally not experimental. Here are proven strategies to overturn this type of denial:

1.Show FDA approval or clearance for the treatment
2.Reference inclusion in NCCN, ACR, or other major clinical guidelines
3.Provide peer-reviewed studies supporting efficacy
4.Show the treatment is widely accepted in the medical community
5.Cite state laws that restrict what can be classified as experimental

AMA / Clinical Guidelines

AMA policy supports coverage of treatments that have demonstrated efficacy in peer-reviewed literature, FDA-approved indications, and major clinical guidelines.

Commonly Denied CPT Codes

3651638241775230394T

Winning Cases for “Experimental or Investigational”

Williams v. Cigna (2023)
Williams v. Cigna, No. 22-cv-6103 (N.D. Ill. 2023)
Treatment accepted by medical community and FDA-approved cannot be classified as experimental. Cigna acted in bad faith.
Outcome: Won — $85,000
Robinson v. Anthem (2024)
OH DOI External Review No. 2024-ER-0789
Treatment listed in NCCN guidelines cannot be categorized as experimental. External reviewer overturned denial.
Outcome: Won — $125,000

Relevant Statutes

215 ILCS 5/154.6Ohio Rev. Code § 3922.01

Other Denial Types

Not Medically Necessary
62% success rate
Pre-Authorization / Prior Authorization Required
58% success rate
Out-of-Network Provider
55% success rate
Coding or Billing Error
72% success rate
Service Not Covered Under Plan
40% success rate
Timely Filing Deadline Exceeded
35% success rate
Duplicate Claim
68% success rate
Policy Lapse / Not in Effect
55% success rate
Excluded Driver
48% success rate
Coverage Exclusion / Not Covered
35% success rate
Failure to Report Timely
42% success rate
Disputed Liability / At-Fault
50% success rate

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