Illinois Administrative Code › Title 50 - INSURANCE › Part 4530 - HEALTH CARRIER EXTERNAL REVIEW › Appendix B - IRO Notice of Decision Template - Experimental and Investigational

Current through Register Vol. 48, No. 28, July 12, 2024
[Independent Review Organization Letterhead]
Notice of Independent Review Decision
[Date of the Notice of the Decision]
RE: IRO Case #:
[Name of Patient]
[Name of IRO] has been certified, by the Illinois Department of
				Insurance (DOI) as an Independent Review Organization (IRO). Illinois
				Department of Insurance has assigned this case to us for independent review in
				accordance with the Illinois Insurance Code and applicable regulations.
The IRO has performed an independent review of the
				proposed/rendered care to determine if the adverse determination was
				appropriate. In the performance of the review, the IRO reviewed the medical
				records and documentation provided to the IRO by involved parties.
IRO NOTICE OF DECISION TEMPLATE
_____________________________________________________________________
This case was reviewed by a [Specialty of Reviewing Physician
				or Health Care Provider]. The reviewer has made a good faith effort to check
				for the existence of any potential conflicts of interest and has signed a
				certification stating that no known conflicts of interest exist between the
				reviewer and the patient, the patient's insurance carrier, the utilization
				review agent (URA), any of the treating physicians or health care providers who
				provided care to the patient, or the URA or insurance carrier health care
				providers who reviewed the case for a decision regarding medical necessity
				before referral to the IRO. In addition, the reviewer has certified that the
				review was performed without bias for or against any party to the
				dispute.
As an officer of [Name of IRO] I certify that:
1. there is no known conflict between the reviewer, the IRO
				and/or any officer/employee of the IRO with any person or entity that is a
				party to the dispute, and
2. a copy of this IRO decision was sent to all of the parties
				via U.S. Postal Service or otherwise transmitted in the manner indicated above
				on [Date].
Sincerely,
[Name of IRO Representative]
[Title]
IRO REVIEWER REPORT TEMPLATE
EXPERIMENTAL OR INVESTIGATIONAL
______________________________________________________________________
-
Date that the IRO Received the Assignment:
Date of Review:
Date of IRO's Decision:
Time Period for which the Review Was Conducted:
IRO Case #:
A General Description of the Reason for the Request for
				External Review:
A Description of the Qualifications for Each Physician or Other
				Health Care Provider Who Reviewed the Decision:
Review Outcome:
Upon independent review the reviewer finds that the previous
				adverse determination/adverse determinations should be:
Upheld(Agree)
Overturned(Disagree)
Partially Overturned(Agree in
				part/Disagree in part)
Provide a description of the review outcome that clearly states
				whether or not medical necessity exists for each of the health care services in
				dispute.
Information Provided to the IRO for Review:
Description of the Covered Person's History (Summary):
Principal Reason or Reasons for its Decision Including Clinical
				Basis, Findings and Conclusions Used to Support the Decision:
Rationale for Decision:
A Description and the Source of the Screening Criteria or Other
				Clinical Basis Used to Make the Decision:
Peer-reviewed scientific studies published in or
				accepted for publication by medical journals that meet nationally recognized
				requirements for scientific manuscripts and that submit most of their published
				articles for review by experts who are not part of the editorial staff;
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 meets 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);
Medical journals recognized by the Secretary of
				Health and Human Services under section 1861(t)(2) of the federal Social
				Security Act;
The following standard reference compendia:
a. The American Hospital Formulary Service Drug
				Information;
b. Drug Facts and Comparisons;
c. The American Dental Association Accepted Dental
				Therapeutics; and
d. The United States Pharmacopoeia Drug
				Information;
Findings, studies, or research conducted by or under
				the auspices of federal government agencies and nationally recognized federal
				research institutes, including:
a. The federal Agency for Healthcare Research and
				Quality;
b. The National Institutes of Health;
c. The National Cancer Institute;
d. The National Academy of Sciences;
e.The Centers for Medicare & Medicaid
				Services;
f. The federal Food and Drug Administration;
				and
g. Any national board recognized by the National
				Institutes of Health for the purpose of evaluating the medical value of health
				care services; or
Any other medical or scientific evidence that is
				comparable to the sources listed above (Provide a Description).
Medical necessity determinations for substance use
				disorders shall be made in accordance with appropriate patient placement
				criteria established by the American Society of Addiction Medicine pursuant to
				Section 370(b)(3) of the Illinois Insurance Code [ 215 ILCS 5 ].
Description of the Covered Person's Medical Condition:
Description of the Indicators Relevant to Whether There Is
				Sufficient Evidence to Demonstrate That the Recommended or Requested Health
				Care Service or Treatment Is More Likely To Be More Beneficial to the Covered
				Person Than Any Available Standard Health Care Services or Treatments and the
				Adverse Risks of the Recommended or Requested Health Care Service or Treatment
				Would Not Be Substantially Increased Over Those of Available Standard Health
				Care Services or Treatments:
Description and Analysis of Any Medical or Scientific Evidence
				Considered in Reaching the Opinion:
Description and Analysis of Any Evidence-based
				Standards:
Whether the Recommended or Requested Health Care Service or
				Treatment Has Been Approved by the Federal Food and Drug Administration for the
				Condition:
Whether Medical or Scientific Evidence or Evidence-based
				Standards Demonstrate That the Expected Benefits of the Recommended or
				Requested Health Care Service or Treatment Is More Likely To Be More Beneficial
				to the Covered Person Than Any Available Standard Health Care Service or
				Treatment and the Adverse Risks of the Recommended or Requested Health Care
				Service or Treatment Would Not Be Substantially Increased Over Those of
				Available Standard Health Care Services or Treatments:
The Written Opinion of the Clinical Reviewer, Including the
				Reviewer's Recommendation as to Whether the Recommended or Requested Health
				Care Service or Treatment Should Be Covered and the Rationale for the
				Reviewer's Recommendation: