# WAC 284-43A-090: WAC 284-43A-090. Additional requirements for experimental or investigational treatment reviews > Washington · Regulations · In force URL: https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_284_43A_090 ## Section - **Citation:** WAC 284-43A-090 - **Heading:** WAC 284-43A-090. Additional requirements for experimental or investigational treatment reviews - **Jurisdiction:** Washington - **Kind:** Regulations - **Status:** In force - **Text as of:** August 14, 2026 - **Source:** Compiled text - **Location:** Washington Administrative Code / Title 284 / Chapter 284-43A / Section 284-43A-090 ## Text (1) In addition to the qualifications listed in WAC 284-43A-060 (3) and (5), at least part of the clinical reviewers' relevant, recent clinical experience must have been obtained in the past three years. (2) Each clinical reviewer shall consider the following information, if appropriate and available, in reaching an opinion: (a) The enrollee's pertinent medical records; (b) The attending physician or health care provider's recommendation; (c) Consulting reports from appropriate health care providers and other documents submitted by the carrier, enrollee, or enrollee's authorized representative, or the enrollee's treating physician or health care provider; and (d) Whether: (i) The terms of coverage under the enrollee's health benefit plan would have covered the treatment had the carrier not determined that the treatment was experimental or investigational; (ii) The recommended or requested health care service or treatment has been approved by the federal Food and Drug Administration, if applicable, for the condition; or (iii) Medical or scientific evidence or evidence-based standards demonstrate that the recommended or requested health care service or treatment is more likely than any available standard health care service or treatment to be beneficial to the enrollee and the adverse risks would not be substantially increased over those of available standard health care services or treatments. (3) Clinical reviewers shall include the following in their written opinions to the IRO: (a) A description of the enrollee's medical condition; (b) A description of the indicators relevant to determining whether there is sufficient evidence to demonstrate that the recommended or requested health care service or treatment is likely to be more beneficial to the enrollee than any available standard health care services or treatments and the adverse risks would not be substantially increased over those of available standard health care services or treatments; of the indicators relevant to determining whether there is sufficient evidence to demonstrate that the recommended or requested health care service or treatment is likely to be more beneficial to the enrollee than any available standard health care services or treatments and the adverse risks would not be substantially increased over those of available standard health care services or treatments; (c) A description and analysis of any medical, scientific evidence, or cost-effectiveness evidence as defined in WAC 284-43A-010 ; (d) A description and analysis of any evidence-based standard as defined in WAC 284-43A-010 ; and (e) Information on whether the reviewer's rationale for the opinion is based on subsection (2)(d) of this section. (4) IROs shall include the following in their notification of the results and rationale for the determination: (a) A general description of the reason for the request for external review; (b) The written opinion of each clinical reviewer, including whether the recommended or requested health care service or treatment should be covered and the rationale for each reviewer's recommendation; (c) The date the review was requested; (d) The date the review was conducted; (e) The date of the IRO's decision; (f) The principle reason or reasons for the IRO's decision; and (g) The rationale for the IRO's decision. ## Nearby sections - [WAC 284-43A-001 WAC 284-43A-001. Purpose and scope](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_284_43A_001.md) - [WAC 284-43A-010 WAC 284-43A-010. Definitions](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_284_43A_010.md) - [WAC 284-43A-020 WAC 284-43A-020. General requirements for certification](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_284_43A_020.md) - [WAC 284-43A-030 WAC 284-43A-030. Application for certification as an IRO](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_284_43A_030.md) - [WAC 284-43A-040 WAC 284-43A-040. Administrative processes and capabilities of IROs](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_284_43A_040.md) - [WAC 284-43A-050 WAC 284-43A-050. Conflict of interest](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_284_43A_050.md) - [WAC 284-43A-060 WAC 284-43A-060. Expert reviewers](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_284_43A_060.md) - [WAC 284-43A-070 WAC 284-43A-070. Independent review process](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_284_43A_070.md) - [WAC 284-43A-080 WAC 284-43A-080. Criteria and considerations for independent review determinations](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_284_43A_080.md) - [WAC 284-43A-090 WAC 284-43A-090. Additional requirements for experimental or investigational treatment reviews](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_284_43A_090.md) - [WAC 284-43A-100 WAC 284-43A-100. Ongoing requirements for IROs](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_284_43A_100.md) - [WAC 284-43A-110 WAC 284-43A-110. Powers of the commissioner](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_284_43A_110.md) - [WAC 284-43A-120 WAC 284-43A-120. Grounds for action against an applicant or a certified IRO](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_284_43A_120.md) - [WAC 284-43A-130 WAC 284-43A-130. Maximum fee schedule](https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_284_43A_130.md) --- Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_WA_ADC_284_43A_090. Check the current official text before relying on it. Not legal advice.