§ 4910. Right to external appeal established. (a) There is hereby\nestablished an insured's right to an external appeal of a final adverse\ndetermination by a health plan.\n (b) An insured, the insured's designee and, in connection with\nconcurrent and retrospective adverse determinations, an insured's health\ncare provider, shall have the right to request an external appeal when:\n (1) (A) the insured has had coverage of the health care service, which\nwould otherwise be a covered benefit under a subscriber contract or\ngovernmental health benefit program, denied on appeal, in whole or in\npart, pursuant to title one of this article on the grounds that such\nhealth care service does not meet the health care plan's requirements\nfor medical necessity, appropriateness, health care setting, level of\ncare, effectiveness of a covered benefit, or other ground consistent\nwith 42 U.S.C. § 300gg-19 as determined by the superintendent, and\n (B) the health care plan has rendered a final adverse determination\nwith respect to such health care service or both the plan and the\ninsured have jointly agreed to waive any internal appeal, or the insured\nis deemed to have exhausted or is not required to complete any internal\nappeal pursuant to section 2719 of the Public Health Service Act, 42\nU.S.C. § 300gg-19; or\n (2) (A) the insured has had coverage of a health care service denied\non the basis that such service is experimental or investigational, and\nsuch denial has been upheld on appeal under title one of this article,\nor both the plan and the insured have jointly agreed to waive any\ninternal appeal, or the insured is deemed to have exhausted or is not\nrequired to complete any internal appeal pursuant to section 2719 of the\nPublic Health Service Act, 42 U.S.C. § 300gg-19, and\n (B) the insured's attending physician has certified that the insured\nhas a condition or disease (a) for which standard health services or\nprocedures have been ineffective or would be medically inappropriate, or\n(b) for which there does not exist a more beneficial standard health\nservice or procedure covered by the health care plan, or (c) for which\nthere exists a clinical trial or rare disease treatment, and\n (C) the insured's attending physician, who must be a licensed,\nboard-certified or board-eligible physician qualified to practice in the\narea of practice appropriate to treat the insured's condition or\ndisease, must have recommended either (a) a health service or procedure\n(including a pharmaceutical product within the meaning of subparagraph\n(B) of paragraph two of subsection (e) of section four thousand nine\nhundred of this article) that, based on two documents from the available\nmedical and scientific evidence, is likely to be more beneficial to the\ninsured than any covered standard health service or procedure or, in the\ncase of a rare disease, based on the physician's certification required\nby subsection (g-7) of section four thousand nine hundred of this\narticle and such other evidence as the insured, the insured's designee\nor the insured's attending physician may present, that the requested\nhealth service or procedure is likely to benefit the insured in the\ntreatment of the insured's rare disease and that such benefit to the\ninsured outweighs the risks of such health service or procedure; or (b)\na clinical trial for which the insured is eligible. Any physician\ncertification provided under this section shall include a statement of\nthe evidence relied upon by the physician in certifying his or her\nrecommendation, and\n (D) the specific health service or procedure recommended by the\nattending physician would otherwise be covered under the policy except\nfor the health care plan's determination that the health service or\nprocedure is experimental or investigational; or\n (3)(A) the insured has had coverage of the health service (other than\na clinical trial to which paragraph two of this subsection shall apply),\nw
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