Prior approval process for experimental and investigational surgical products and medical devices — Definition

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  1. (a) As used in this section:

    1. (1) “Health carrier” means a:

      1. (A) Health maintenance organization;

      2. (B) Hospital medical service corporation; and

      3. (C) Disability insurance company;

    2. (2) “Health carrier” includes a:

      1. (A) Self-insured governmental or church plan; and

      2. (B) Third-party administrator that administers or adjusts disability benefits for a disability insurer, hospital medical service corporation, health maintenance organization, self-insured governmental plan, or self-insured church plan; and

    3. (3) “Health carrier” does not include:

      1. (A) An automobile insurer paying medical or hospital benefits under § 23-89-202(1) or a self-insured employer health benefits plan; or

      2. (B) A person, company, or organization licensed or registered to issue or that issues an insurance policy or insurance contract in this state as described in §§ 23-62-102 and 23-62-104 — 23-62-107 providing medical or hospital benefits for accidental injury or disability.

  2. (b) A health carrier that excludes or denies coverage for a specific surgical product or medical device approved for marketing by the United States Food and Drug Administration as experimental or investigational, or both, shall develop a process by which a surgeon, before utilizing the surgical product or medical device, may present medical evidence to obtain a review for the individual patient for coverage of the surgical product or medical device.


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