South Dakota Administrative Rules
Title 20 - PUBLIC SAFETY
Article 20:06 - INSURANCE
Chapter 20:06:53 - External and internal review
Section 20:06:53:47 - Clinical review criteria for experimental or investigational treatment reviews
Current through Register Vol. 50, page 114, March 25, 2024
In addition to the documents and information provided pursuant to §§ 20:06:53:33 to 20:06:53:35, inclusive, or § 20:06:53:42, each clinical reviewer selected pursuant to §§ 20:06:53:39 to 20:06:53:41, inclusive, to the extent the information or documents are available and the reviewer considers appropriate, shall consider in reaching an opinion pursuant to §§ 20:06:53:45 and 20:06:53:46, the following:
(1) The covered person's pertinent medical records;
(2) The attending physician or health care professional's recommendation;
(3) Consulting reports from appropriate health care professionals and other documents submitted by the health carrier, covered person, the covered person's authorized representative, or the covered person's treating physician or health care professional;
(4) The terms of coverage under the covered person's health benefit plan with the health carrier to ensure that, but for the health carrier's determination that the recommended or requested health care service or treatment that is the subject of the opinion is experimental or investigational, the reviewer's opinion is not contrary to the terms of coverage under the covered person's health benefit plan with the health carrier; and
(5) Whether:
General Authority: SDCL 58-17-87, 58-17H-49, 58-17I-16, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79.