<html xmlns="http://www.w3.org/1999/xhtml"><head><meta charset="UTF-8" /><title></title><meta name="Generator" content="PowerTools for Open XML" /><style>span { white-space: pre-wrap; } p.s98aedba7-e6d4-4317-b99e-4cc2db100429Normal { text-align: justify; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; margin-top: 0; margin-left: 0; margin-right: 0; margin-bottom: .001pt; } span.s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont-000000 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s98aedba7-e6d4-4317-b99e-4cc2db100429000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont-000002 { color: #0000FF; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </style></head><body><div><p dir="ltr" class="s98aedba7-e6d4-4317-b99e-4cc2db100429Normal"><span xml:space="preserve" class="s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont">    </span><span class="s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont-000000">20:06:21:08.  "Medically necessary" defined.</span><span xml:space="preserve" class="s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont"> 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.</span></p><p dir="ltr" class="s98aedba7-e6d4-4317-b99e-4cc2db100429Normal"><span xml:space="preserve" class="s98aedba7-e6d4-4317-b99e-4cc2db100429000001"> </span></p><p dir="ltr" class="s98aedba7-e6d4-4317-b99e-4cc2db100429Normal"><span xml:space="preserve" class="s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont">    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.</span></p><p dir="ltr" class="s98aedba7-e6d4-4317-b99e-4cc2db100429Normal"><span xml:space="preserve" class="s98aedba7-e6d4-4317-b99e-4cc2db100429000001"> </span></p><p dir="ltr" class="s98aedba7-e6d4-4317-b99e-4cc2db100429Normal"><span xml:space="preserve" class="s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont">    </span><span class="s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont-000000">Source:</span><span xml:space="preserve" class="s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont"> 16 SDR 208, effective </span><span class="s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont">June 3, 1990.</span></p><p dir="ltr" class="s98aedba7-e6d4-4317-b99e-4cc2db100429Normal"><span xml:space="preserve" class="s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont">    </span><span class="s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont-000000">General Authority:</span><span xml:space="preserve" class="s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=58-4-1"><span class="s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont-000002">58-4-1</span></a><span xml:space="preserve" class="s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont">, </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17B-4"><span class="s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont-000002">58-17B-4</span></a><span xml:space="preserve" class="s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont">, </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17B-15"><span class="s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont-000002">58-17B-15</span></a><span class="s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont">.</span></p><p dir="ltr" class="s98aedba7-e6d4-4317-b99e-4cc2db100429Normal"><span xml:space="preserve" class="s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont">    </span><span class="s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont-000000">Law Implemented:</span><span xml:space="preserve" class="s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17B-4"><span class="s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont-000002">58-17B-4</span></a><span class="s98aedba7-e6d4-4317-b99e-4cc2db100429DefaultParagraphFont">.</span></p><p dir="ltr" class="s98aedba7-e6d4-4317-b99e-4cc2db100429Normal"><span xml:space="preserve" class="s98aedba7-e6d4-4317-b99e-4cc2db100429000001"> </span></p></div></body></html>