28-13-27.1. Medically necessary hospital services.

Medically necessary hospital services are services provided in a hospital which meet the following criteria:

(1)    Are consistent with the person's symptoms, diagnosis, condition, or injury;

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

(3)    Are provided in response to a life-threatening condition; to treat pain, injury, illness, or infection; to treat a condition which would result in physical or mental disability; or to achieve a level of physical or mental function consistent with prevailing standards for the diagnosis or condition;

(4)    Are not furnished primarily for the convenience of the person or the provider; and

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

A county shall rely on the attending physician's determination as to medical necessity of hospital services unless evidence exists to the contrary.

Source: SL 1997, ch 170, § 5.