As used in this chapter, "adverse determination" means a denial of a request for benefits on the grounds that the health service or item:

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.