20:06:53:45. Clinical review opinion for experimental or investigational treatment reviews. Except as provided in § 20:06:53:44, within 20 days after being selected in accordance with §§ 20:06:53:39 to 20:06:53:41, inclusive, to conduct the external review, each clinical reviewer shall provide an opinion to the assigned independent review organization pursuant to § 20:06:53:47 on whether the recommended or requested health care service or treatment should be covered. Except for an opinion provided pursuant to § 20:06:53:46, each clinical reviewer's opinion shall be in writing and include the following information:
(1) A description of the covered person's medical condition;
(2) A description of the indicators relevant to determining whether there is sufficient evidence to demonstrate that 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 services or treatments 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;
(3) A description and analysis of any medical or scientific evidence, as that term is defined in subdivision 20:06:53:01(28), considered in reaching the opinion;
(4) A description and analysis of any evidence-based standard, as that term is defined in subdivision 20:06:53:01(18); and
(5) Information on whether the reviewer's rationale for the opinion is based on subsection 20:06:53:47(5)(a) or (b).
Source: 37 SDR 48, effective September 22, 2010; 37 SDR 241, effective July 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.
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