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Code of Federal Regulations (Last Updated: July 5, 2024) |
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Title 42 - Public Health |
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Chapter IV - Centers for Medicare & Medicaid Services, Department of Health and Human Services |
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SubChapter D - State Children'S Health Insurance Programs (Schips) |
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Part 466 - UTILIZATION AND QUALITY CONTROL REVIEW |
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Subpart C - Review Responsibilities of Utilization and Quality Control Peer Review Organizations (PROs) |
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PRO Review Functions |
§ 466.83 - Initial denial determinations.
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A determination by a PRO that the health care services furnished or proposed to be furnished to a patient are not medically necessary, are not reasonable, or are not at the appropriate level of care, is an initial denial determination and is appealable under part 473 of this chapter.