1. (1) For coverage denial determinations other than experimental treatment determinations, independent review organizations shall consider any of the following:

   1. (a) Medical or scientific evidence including evidence that is determined to be an efficacious treatment or strategy as defined at s. Ins 3.36 (3) (c).
   2. (b) Legal basis.
   3. (c) The applicable insurance contract.
2. (2) Independent review organizations shall include as members or advisors an attorney or actuary when the dispute involves a rescission, reformation or the dispute includes a legal dispute. The addition of an attorney or actuary to a review panel is at the discretion of the independent review organization or reviewers and need only be considered when the independent review organization or reviewers determine additional expertise would provide appropriate and necessary assistance in the review.

History

History: CR 10-023: cr. Register September 2010 No. 657, eff. 10-1-10.