Selection of Reviewer

The selection of reviewers in a particular case is made by the contractor based on the type of medical services involved in the dispute. Due to the usual complexity, three physicians review investigational and experimental cases; medical necessity cases are normally reviewed by a single reviewer. Additional reviewers may be assigned to medical necessity reviews in complex cases or when the issues presented may not be adequately reflected in one reviewer's experience or expertise. For each case, reviewers must confirm they are knowledgeable of the treatment at issue, that they have treated patients with the condition at issue and that they are credentialed or have privileges from a licensed health care facility in the diagnosis and treatment of the medical condition at issue. In general, cases are sent to either the same specialty as the patient's treating provider or the specialty that the patient has requested that the plan provide.