14 Va. Admin. Code § 10-10-220

Current through Register Vol. 41, No. 8, December 2, 2024

Section 14VAC10-10-220 - Experimental treatment and therapy

A. Experimental treatments or therapy not typically covered by health insurance, including conductive education, may be covered up to a maximum of $6,000 per year, combined, with written prior authorization from the Executive Director of the Virginia Birth-Related Neurological Injury Compensation Program (Program). The Board of Directors of the Program recognizes that such therapies or treatments may be useful for some admitted claimants and, therefore, grants this discretionary benefit on a case-by-case basis. Because this benefit is not provided expressly by the Virginia Birth-Related Neurological Injury Compensation Act (§ 38.2-5000 et seq. of the Code of Virginia), however, there is no guarantee of coverage for experimental therapy or treatment. This completely discretionary benefit may be rescinded at any time; especially if such rescission is warranted by the Board of Directors fiduciary obligations set forth in § 38.2-5016F of the Code of Virginia. Upon such rescission, benefits under this policy will terminate immediately and no admitted claimant will have any further recourse or any basis for a claim for further benefits under this policy.

B. A written request for authorization of experimental treatment or therapy must be submitted to the Program in accordance with the following process:

1. A letter of medical necessity from the admitted claimant's physiatrist, neurologist, or other appropriate treating specialist physician, who also regularly treats other patients with cerebral palsy, must be received by the Program. A letter of medical necessity from a physical therapist is not acceptable.

2. The letter of medical necessity must be received in the Program's offices at least 60 days prior to the desired start of treatment.

3. Evidence as to whether the primary insurers or other payers will cover any portion of the cost must be submitted with the request.

4. At the Program's discretion, all requests for experimental treatments or therapies may be reviewed for medical necessity by an objective qualified physician.

C. All other Program regulations regarding therapies, including the travel policy, are applicable to authorized experimental treatments or therapies. These include:

1. Payment for travel, lodging, and meals on a per diem basis based on current Commonwealth of Virginia rates.

2. For travel other than by car or van, prior authorization must be obtained.

D. Written authorization from the Program must be obtained by the admitted claimant prior to any payments or reimbursements being made by the Program.

E. Total combined costs for experimental treatments or therapies, related equipment, and travel expenses during any single calendar year may not exceed $6,000.

F. Following any experimental therapy treatment, a complete and thorough progress report prepared by the treating facility must be submitted to the Program within 60 days of completion of the therapy.

G. No further sessions or treatments will be authorized prior to the Program's receiving such progress reports. The receipt of the reports does not guarantee that further treatments will be authorized.

H. The Program may request an independent progress evaluation by a qualified physician prior to any reauthorization for subsequent treatments. If the admitted claimant's insurance will not cover this evaluation, the Program will pay for the evaluation at usual and customary rates. If the Program pays for the evaluation, that cost will not be considered to be part of the cost of the treatment.

I. A local qualified provider of the experimental therapy or treatment requested should be utilized unless the Program grants an exception for a specific treatment provider.

J. For any therapy or treatment proposed, no more than 100 hours will be authorized upon initial request. Additional authorization may be provided only after the procedures in subsection F of this section have been followed.

K. Nursing, certified nurse aide, or other personal assistance will not be provided for extended experimental therapy sessions of more than two hours per day unless a letter of medical necessity is received by the Program from an appropriate treating specialist physician. The letter must state specifically that a nurse must be present due to specified health risks to the admitted claimant.

L. In determining whether authorization will be granted for experimental therapy or treatment, the Program will consider, including the following:

1. The overall cost associated with the experimental treatment or therapy. The cost for one person to accompany the admitted claimant, if stated to be medically necessary by the treating physician; the duration of the Program; the expected benefits to the admitted claimant; and the availability of the experimental program in Virginia.

2. The report from the admitted claimant's treating physician regarding the medical necessity for the admitted claimant to participate in the experimental program.

3. Whether there is medically recognized proof of results that the experimental therapy or treatment has benefitted other patients in similar circumstances.

4. The expected frequency and duration of the experimental treatment or therapy requested.

5. The Program may require third party medical reviews to evaluate the potential success, safety, or results of the experimental treatment or therapy.

M. The Program encourages families to seek out clinical trials being conducted by accredited medical facilities, medical schools, or other highly regarded and medically accepted facilities or organizations to help establish the medical efficacy of experimental treatments or therapies.

14 Va. Admin. Code § 10-10-220

Derived From Virginia Register Volume 33, Issue 23, eff. 7/10/2017.

Statutory Authority: § 38.2-5002.1 of the Code of Virginia.