(a) A utilization review agent shall use written medically acceptable screening criteria
and review procedures that are established and periodically evaluated and updated
with appropriate involvement from physicians, including practicing physicians, dentists,
and other health care providers.
(b) A utilization review determination shall be made in accordance with currently
accepted medical or health care practices, taking into account special circumstances
of the case that may require deviation from the norm stated in the screening criteria.
(c) Screening criteria must be:
(2) clinically valid;
(3) compatible with established principles of health care; and
(4) flexible enough to allow a deviation from the norm when justified on a case-by-case
(d) Screening criteria must be used to determine only whether to approve the requested
treatment. A denial of requested treatment must be referred to an appropriate physician, dentist,
or other health care provider to determine medical necessity.
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