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Medical Necessity in Private Health Plans
Table 9. Independent Reviews: Standard of Review for Medical Necessity Determinations
| Jurisdiction |
De Novo |
Other |
If Standard is De Novo or Not Specified,
Can Insured Submit Additional Evidence? (X if yes) |
| Alaska
|
X
|
|
|
| Arizona
|
|
|
X |
| California
|
|
|
X |
| Colorado
|
X
|
|
X |
| Connecticut
|
|
|
X |
| Delaware
|
|
|
X |
| District of Columbia
|
|
|
X (Insured can also request a hearing before IRO.) |
| Florida
|
|
|
|
| Georgia
|
|
|
X |
| Hawaii
|
|
|
|
| Illinois
|
|
|
|
| Indiana
|
|
|
X |
| Iowa
|
X
|
|
X |
| Kansas
|
|
|
X |
| Kentucky
|
|
|
X |
| Louisiana
|
|
|
|
| Maine
|
|
|
X (Patient may attend the external review, ask questions of the insurance company representative, and use outside assistance such as counsel [at the patient's expense].) |
| Maryland1
|
|
|
X |
| Massachusetts
|
|
|
|
| Michigan
|
X
|
|
X |
| Minnesota
|
|
|
X |
| Missouri
|
|
|
X |
| Montana
|
|
|
|
| New Hampshire
|
X
|
|
X |
| New Jersey
|
|
|
|
| New Mexico
|
|
|
X (Hearing officer and co-medical hearing officers conduct hearing with witnesses and presentation of evidence.) |
| New York
|
|
|
X |
| North Carolina
|
|
|
X |
| Ohio
|
|
|
X |
| Oklahoma
|
|
|
X |
| Oregon
|
|
|
To Be Determined |
| Pennsylvania
|
|
|
X |
| Rhode Island
|
|
|
|
| South Carolina
|
X
|
|
X |
| Tennessee
|
|
|
|
| Texas
|
|
|
X |
| Utah
|
|
|
|
| Vermont
|
|
|
X |
| Virginia
|
|
|
|
| Washington
|
|
|
X |
| West Virginia
|
|
|
|
1 Maryland's IRO statute places the burden of proof on the MCO to demonstrate that its initial adverse decision was correct. Md. Ins. Code Ann. ß 15-10A-03(e) (2001).
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