Bill > HB4197

This bill mandates that health insurance plans, including those offered by managed care organizations (MCOs), must cover physician-prescribed treatments deemed medically necessary for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS). The bill defines "medically necessary" as treatments that are within the scope of benefits, recommended by a physician or licensed healthcare provider, required to diagnose or treat the condition, safe and effective, the least costly adequate alternative, and not experimental or investigational. It specifies that coverage must include antibiotics, medication, behavioral therapies, immunomodulating medicines, plasma exchange, and intravenous immunoglobulin therapy, with no greater co-payment, deductible, or coinsurance than similar benefits. The bill also prohibits denial or delay of coverage solely based on prior treatment or a different diagnostic name, and requires adherence to treatment recommendations from a medical professional consortium based on evidence of positive patient outcomes, with no lifetime or policy period limits on coverage. For billing, PANDAS and PANS will be coded as autoimmune encephalitis until specific codes are created by the American Medical Association and Centers for Medicare and Medicaid Services.

Health and Social Services

http://www.wvlegislature.gov/Bill_Status/Bills_history.cfm?input=4197&year=2026&sessiontype=RS&btype=bill