(a)As used in this chapter:
(i)"Health care provider" means any physician,
hospital or other person licensed or otherwise authorized in
this or another state to furnish to any individual medical or
dental care, vision care or hospitalization incident to the
furnishing of that care or hospitalization for the purpose of
preventing, alleviating, curing or healing human illness, injury
or physical disability;
(ii)"Usual, customary and reasonable basis" means
the method by which an insurer determines the amount to be paid
on a claim for disability benefits by comparing the amount of
the claim to amounts charged by other health care providers for
the same or similar medical services or procedures;
(iii)"Medical necessity," means:
(A)A medical service, procedure or supply
provided for the pu
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(a) As used in this chapter:
(i) "Health care provider" means any physician,
hospital or other person licensed or otherwise authorized in
this or another state to furnish to any individual medical or
dental care, vision care or hospitalization incident to the
furnishing of that care or hospitalization for the purpose of
preventing, alleviating, curing or healing human illness, injury
or physical disability;
(ii) "Usual, customary and reasonable basis" means
the method by which an insurer determines the amount to be paid
on a claim for disability benefits by comparing the amount of
the claim to amounts charged by other health care providers for
the same or similar medical services or procedures;
(iii) "Medical necessity," means:
(A) A medical service, procedure or supply
provided for the purpose of preventing, diagnosing or treating
an illness, injury, disease or symptom and is a service,
procedure or supply that:
(I) Is medically appropriate for the
symptoms, diagnosis or treatment of the condition, illness,
disease or injury;
(II) Provides for the diagnosis, direct
care and treatment of the patient's condition, illness, disease
or injury;
(III) Is in accordance with professional,
evidence based medicine and recognized standards of good medical
practice and care; and
(IV) Is not primarily for the convenience
of the patient, physician or other health care provider.
(B) A medical service, procedure or supply shall
not be excluded from being a medical necessity under this
section solely because the service, procedure or supply is not
in common use if the safety and effectiveness of the service,
procedure or supply is supported by:
(I) Peer reviewed medical literature,
including literature relating to therapies reviewed and approved
by a qualified institutional review board, biomedical compendia
and other medical literature that meet the criteria of the
National Institutes of Health's Library of Medicine for indexing
in Index Medicus (Medline) and Elsevier Science Ltd. for
indexing in Excerpta Medicus (EMBASE); or
(II) Medical journals recognized by the
Secretary of Health and Human Services under Section 1861(t)(2)
of the federal Social Security Act.