(1) DEFINITIONS. In this section: (a) “Health care plan” has the meaning given in s. 628.36 (2) (a) 1. (b) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c). (2) DISCLOSURE OF LIMITATIONS. Subject to s. 632.87 (6), a health care plan or a self-insured health plan that limits coverage of experimental treatment shall define the limitation and disclose the limits in any agreement, policy or certificate of coverage. This disclosure shall include the following information: (a) Who is authorized to make a determination on the limitation. (b) The criteria the plan uses to determine whether a treatment, procedure, drug or device is experimental. (3) DENIAL OF TREATMENT. (am) A health care plan or a self-insured health plan that receives a request for prior authorization of an experimental procedure that includes all of the required information upon which to make a decision shall, within 5 working days after receiving the request, issue a coverage decision. If the health care plan or self-insured health plan denies coverage of an experimental treatment, procedure, drug or device for an insured who has a terminal condition or illness, the health care plan or self-insured health plan shall, as part of its coverage decision, provide the insured with a denial letter that includes all of the following: 1. A statement setting forth the specific medical and scientific reasons for denying coverage. 2. Notice of the insured’s right to appeal and a description of the appeal procedure. (bm) A health care plan or a self-insured health plan may not deny coverage under par. (am) of an experimental treatment, procedure, drug, or device for an insured if the denial violates s. 632.87 (6).
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