632.835(2)(d) (d) An insured is not required to exhaust the internal grievance procedure under s. 632.83 before requesting an independent review if any of the following apply:

632.835(2)(d)1. 1. The insured and the insurer agree that the matter may proceed directly to independent review under sub. (3).

632.835(2)(d)2. 2. Along with the notice to the insurer of the request for independent review under sub. (3) (a), the insured submits to the independent review organization selected by the insured a request to bypass the internal grievance procedure under s. 632.83 and the independent review organization determines that the health condition of the insured is such that requiring the insured to use the internal grievance procedure before proceeding to independent review would jeopardize the life or health of the insured or the insured’s ability to regain maximum function.

632.835(2)(e) (e) Nothing in this section affects an insured’s right to commence a civil proceeding relating to a coverage denial determination.

632.835(3) (3) Procedure.

632.835(3)(a) (a) To request an independent review, an insured or his or her authorized representative shall provide timely written notice of the request for independent review, and of the independent review organization selected, to the insurer that made or on whose behalf was made the coverage denial determination. The insurer shall immediately notify the commissioner and the independent review organization selected by the insured of the request for independent review. For each independent review in which it is involved, an insurer shall pay a fee to the independent review organization.

632.835(3)(b) (b) Within 5 business days after receiving written notice of a request for independent review under par. (a), the insurer shall submit to the independent review organization copies of all of the following:

632.835(3)(b)1. 1. Any information submitted to the insurer by the insured in support of the insured’s position in the internal grievance under s. 632.83.

632.835(3)(b)2. 2. The contract provisions or evidence of coverage of the insured’s health benefit plan.

632.835(3)(b)3. 3. Any other relevant documents or information used by the insurer in the internal grievance determination under s. 632.83.

632.835(3)(c) (c) Within 5 business days after receiving the information under par. (b), the independent review organization shall request any additional information that it requires for the review from the insured or the insurer. Within 5 business days after receiving a request for additional information, the insured or the insurer shall submit the information or an explanation of why the information is not being submitted.

632.835(3)(d) (d) An independent review under this section may not include appearances by the insured or his or her authorized representative, any person representing the health benefit plan or any witness on behalf of either the insured or the insurer.

632.835(3)(e) (e) In addition to the information under pars. (b) and (c), the independent review organization may accept for consideration any typed or printed, verifiable medical or scientific evidence that the independent review organization determines is relevant, regardless of whether the evidence has been submitted for consideration at any time previously. The insurer and the insured shall submit to the other party to the independent review any information submitted to the independent review organization under this paragraph and pars. (b) and (c). If, on the basis of any additional information, the insurer reconsiders the insured’s grievance and determines that the treatment that was the subject of the grievance should be covered, or that the policy or certificate that was rescinded should be reinstated, the independent review is terminated.

632.835(3)(f) (f)

632.835(3)(f)1. 1. If the independent review is not terminated under par. (e), the independent review organization shall, within 30 business days after the expiration of all time limits that apply in the matter, make a decision on the basis of the documents and information submitted under this subsection. The decision shall be in writing, signed on behalf of the independent review organization and served by personal delivery or by mailing a copy to the insured or his or her authorized representative and to the insurer. Except as provided in subd. 2., a decision of an independent review organization is binding on the insured and the insurer.

632.835(3)(f)2. 2. A decision of an independent review organization regarding a preexisting condition exclusion denial determination or a rescission is not binding on the insured.

632.835(3)(g) (g) If the independent review organization determines that the health condition of the insured is such that following the procedure outlined in pars. (b) to (f) would jeopardize the life or health of the insured or the insured’s ability to regain maximum function, the procedure outlined in pars. (b) to (f) shall be followed with the following differences:

632.835(3)(g)1. 1. The insurer shall submit the information under par. (b) within one day after receiving the notice of the request for independent review under par. (a).

632.835(3)(g)2. 2. The independent review organization shall request any additional information under par. (c) within 2 business days after receiving the information under par. (b).

632.835(3)(g)3. 3. The insured or insurer shall, within 2 days after receiving a request under par. (c), submit any information requested or an explanation of why the information is not being submitted.

632.835(3)(g)4. 4. The independent review organization shall make its decision under par. (f) within 72 hours after the expiration of the time limits under this paragraph that apply in the matter.

632.835(3m) (3m) Standards for decisions.

632.835(3m)(a) (a) A decision of an independent review organization regarding an adverse determination or a preexisting condition exclusion denial determination must be consistent with the terms of the health benefit plan under which the adverse determination or preexisting condition exclusion denial determination was made.

632.835(3m)(b) (b) A decision of an independent review organization regarding an experimental treatment determination is limited to a determination of whether the proposed treatment is experimental. The independent review organization shall determine that the treatment is not experimental and find in favor of the insured only if the independent review organization finds all of the following:

632.835(3m)(b)1. 1. The treatment has been approved by the federal food and drug administration, if the treatment is subject to the approval of the federal food and drug administration.

632.835(3m)(b)2. 2. Medically and scientifically accepted evidence clearly demonstrates that the treatment meets all of the following criteria:

632.835(3m)(b)2.a. a. The treatment is proven safe.

632.835(3m)(b)2.b. b. The treatment can be expected to produce greater benefits than the standard treatment without posing a greater adverse risk to the insured.

632.835(3m)(b)2.c. c. The treatment meets the coverage terms of the health benefit plan and is not specifically excluded under the terms of the health benefit plan.