As used in this chapter, "adverse determination" means a decision by a utilization review entity to deny, reduce, or terminate benefit coverage of a health care service furnished or proposed to be furnished to a covered individual on the grounds that the health care service:

1. (1) is not medically necessary, appropriate, effective, or efficient;
2. (2) is not being provided in or at an appropriate health care setting or level of care; or
3. (3) is experimental or investigational.

As added by P.L.190-2023, SEC.14. Amended by P.L.144-2025, SEC.3.