S.D. Admin. R. 67:16:01:06.02

Current through Register Vol. 50, page 162, June 24, 2024

Section 67:16:01:06.02 - Covered services must be medically necessary

Services covered under this article must be medically necessary. To be medically necessary, the covered service must meet the following conditions:

(1) It is consistent with the recipient's symptoms, diagnosis, condition, or injury;

(2) It is recognized as the prevailing standard and is consistent with generally accepted professional medical standards of the provider's peer group;

(3) It is provided in response to a life-threatening condition; to treat pain, injury, illness, or infection; to treat a condition that could result in physical or mental disability; or to achieve a level of physical or mental function consistent with prevailing community standards for diagnosis or condition;

(4) It is not furnished primarily for the convenience of the recipient or the provider; and

(5) There is no other equally effective course of treatment available or suitable for the recipient requesting the service which is more conservative or substantially less costly.

S.D. Admin. R. 67:16:01:06.02

17 SDR 184, effective 6/6/1991.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.