Indiana § 27-1-37.5-5.4 "Medically necessary"

Indiana Statutes

§ 27-1-37.5-5.4 — "Medically necessary"

Indiana § 27-1-37.5-5.4

Title 27INSURANCE

Art. 1DEPARTMENT OF INSURANCE

Ch. 37.5Health Care Service Prior Authorization

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Bluebook

Ind. Code § 27-1-37.5-5.4 (2026).

Text

4. As used in this chapter, "medically necessary" means a health care service that a prudent health care provider would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or symptoms in a manner that is:

(1)in accordance with generally accepted standards of medical practice;

(2)clinically appropriate in terms of type, frequency, extent, site, and duration; and

(3)not primarily for:

(A)the economic benefit of the health plan or purchaser; or

(B)the convenience of the health plan, patient, treating physician, or other health care provider.

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4. As used in this chapter, "medically
necessary" means a health care service that a prudent health care
provider would provide to a patient for the purpose of preventing,
diagnosing, or treating an illness, injury, disease, or symptoms in a
manner that is:
(1) in accordance with generally accepted standards of medical
practice;
(2) clinically appropriate in terms of type, frequency, extent, site,
and duration; and
(3) not primarily for:
(A) the economic benefit of the health plan or purchaser; or
(B) the convenience of the health plan, patient, treating
physician, or other health care provider.