Rule 120-2-111-.07 - Independent Review Organization Decision(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.Ga. Comp. R. & Regs. R. 120-2-111-.07
O.C.G.A. §§ 33-2-9, 33-20A-41.
Original Rule entitled "Independent Review Organization Decision" adopted. F. Sept. 20, 2023; eff. August 1, 2023, as specified by the Agency.