Section 4530.APPENDIX B   IRO Notice of Decision Template – Experimental and Investigational

 

 

[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:

 

(Source:  Amended at 39 Ill. Reg. 4077, effective September 1, 2015)