Defining Experimental Therapy — A Third-Party Payer's Dilemma

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Abstract
A young Maryland mother discovered that she had relapsed only six months after receiving adjuvant chemotherapy for breast cancer. Assessing her poor prognosis, the woman's oncologist recommended high-dose chemotherapy with autologous bone marrow transplantation. Her insurer, Blue Cross and Blue Shield of Virginia, denied coverage for the treatment, citing a clause in the policy that excluded "experimental" therapy. After hearing the case, a federal judge ordered the insurer to pay for the treatment, stating that the policy did not specify the criteria that defined a treatment as experimental.1 This case is representative of a dilemma for third-party payers. The majority . . .

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