10 CCR 2505-10-8.190 - ACUTE MEDICAL BENEFITS DETERMINATION
8.190.1 A client or provider may request a
coverage determination for new acute medical benefits or services by submitting
a written request to the Department.
8.190.1.A. Written requests shall include
documentation on all the following criteria regarding the benefit or service:
1. Prescribed by a doctor of medicine or
osteopathy, or an optometrist, dentist or podiatrist acting within the scope of
their respective licenses;
2. A
reasonable, appropriate and effective method for meeting the medical
need;
3. The expected use is in
accordance with current medical standards or practices;
4. Proven cost effective method of
treatment;
5. Does not result in an
unsafe environment or situation;
6.
Not experimental, investigational and is accepted by the medical community as
standard practice;
7. Primary
purpose is not to enhance personal comfort or convenience; and
8. Considered to be medically necessary for
the diagnosis.
8.190.2 The requestor shall be notified in
writing of the Department's decision regarding coverage.
Notes
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