§ 26-55-106 — Requirements applicable to persons reviewing appeals

(a) Each health insurer or contracted utilization review
entity shall ensure that all appeals of adverse determinations
are reviewed by a physician or other appropriate licensed health
care provider who has:
(i) Sufficient medical knowledge in an applicable
practice area or specialty;
(ii) Knowledge of the coverage criteria;
(iii) A current and unrestricted license to practice
within the scope of their medical profession in a state,
territory, commonwealth of the United States or the District of
Columbia;
(iv) Not been employed by the health insurer or
contracted utilization review entity or been under contract with
the health insurer or contracted utilization review entity other
than to participate in one (1) or more of the health insurer or
contracted utilization review entity's health care provider
networks or to perform reviews of appeals, or otherwise have any
financial interest in the outcome of the appeal;
(v) Not been directly involved in the initial adverse
determination; and
(vi) Considered all known clinical aspects of the
health care service under review, including but not limited to,
a review of all pertinent medical records provided to the health
insurer or contracted utilization review entity by the
enrollee's health care provider, any relevant records provided
to the health insurer or contracted utilization review entity by
a health care facility, any pertinent material provided by the
enrollee and any medical literature provided to the health
insurer or contracted utilization review entity by the health
care provider.
(b) The enrollee's health care provider may request upon
the initiation of an appeal that the appeal from an adverse
determination be made by a physician or a specialist in the area
of medicine under appeal.