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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