S.D. Admin. R. 20:06:53:47

Current through Register Vol. 50, page 159, June 17, 2024

Section 20:06:53:47 - Clinical review criteria for experimental or investigational treatment reviews

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:

(a) The recommended or requested health care service or treatment has been approved by the federal Food and Drug Administration, if applicable, for the condition; or

(b) Medical or scientific evidence or evidence-based standards demonstrate that the expected benefits of the recommended or requested health care service or treatment is more likely than not to be beneficial to the covered person than any available standard health care service or treatment and the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services or treatments.

S.D. Admin. R. 20:06:53:47

37 SDR 48, effective 9/22/2010; 37 SDR 241, effective 7/1/2011.

General Authority: SDCL 58-17-87, 58-17H-49, 58-17I-16, 58-18-79.

Law Implemented: SDCL 58-17-87, 58-18-79.