Compilation of Rules and Regulations of the State of Georgia
Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER
Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE
Subject 120-2-111 - PATIENT'S RIGHT TO INDEPENDENT REVIEW
Rule 120-2-111-.07 - Independent Review Organization Decision

Universal Citation: GA Rules and Regs r 120-2-111-.07

Current through Rules and Regulations filed through September 23, 2024

(1) The expert reviewer of the independent review organization shall make a determination as to whether a treatment is experimental based upon the following criteria:

(a) Whether such treatment has been approved by the federal Food and Drug Administration; or

(b) Whether medical and scientific evidence demonstrates that the expected benefits of the proposed treatment would be greater than the benefits of any available standard treatment and that the adverse risks of the proposed treatment will not be substantially increased over those of standard treatments.

(c) For either determination, the expert reviewer shall apply prudent professional practices and shall assure that at least two documents of medical and scientific evidence support the decision. The expert reviewer shall take into account evidence and opinions of practitioners in the field who are experts in the treatment proposed to be offered.

(2) In making a decision as to whether a treatment is medically necessary or appropriate, the expert reviewer shall use the definition of medical necessity, medically necessary care, and medically necessary and appropriate, as defined in these Rules and the Act. Criteria must be objective, clinically valid, compatible with established principles of health care, and flexible enough to allow deviations from the norms when justified on a case-by-case basis.

O.C.G.A. §§ 33-2-9, 33-20A-41.

Disclaimer: These regulations may not be the most recent version. Georgia may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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