Rule 20:06:21:08 "Medically necessary" defined.
20:06:21:08. "Medically necessary" defined.
When "medically necessary" is used as a condition to qualify for
benefits, it may not be defined more restrictively than as requiring the
certification of the insured's physician.
If a policy does not have a prior
hospitalization requirement, then the following definition of medical necessity
may be used: Treatment that is appropriate and consistent with the diagnosed
condition. This is treatment, that, in accordance with
accepted medical standards, could not have been omitted without adversely
affecting the patient's condition. This definition of medical necessity may not
be used for policies which condition benefits on inability to perform ADLs or functional incapacity.
16 SDR 208, effective June 3, 1990.
Authority: SDCL 58-4-1, 58-17B-4, 58-17B-15.
Implemented: SDCL 58-17B-4.
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