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          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.

 

          Source: 17 SDR 184, effective June 6, 1991.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

 


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