Sec. 203. Exclusions and limitations
401 words·~2 min read·
/bill/116/hr/1384/ih/section-203·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Benefits for items and services are not available under this Act unless the items and services meet the standards developed by the Secretary pursuant to section 201(a). In applying subsection (a), the Secretary shall make national coverage determinations with respect to items and services that are experimental in nature. Such determinations shall be consistent with the national coverage determination process as defined in section 1869(f)(1)(B) of the Social Security Act ( 42 U.S.C. 1395ff(f)(1)(B) ).
The Secretary shall establish a process by which individuals can appeal coverage decisions. The process shall, as much as is feasible, follow the process for appeals under the Medicare program described in section 1869 of the Social Security Act ( 42 U.S.C. 1395ff ). In the case of items and services for which the Department of Health and Human Services has recognized a national practice guideline, such items and services shall be deemed to meet the standards specified in section 201(a) if they have been provided in accordance with such guideline.
For purposes of this subsection, an item or service not provided in accordance with a practice guideline shall be deemed to have been provided in accordance with the guideline if the health care provider providing the item or service— exercised appropriate professional judgment in accordance with the laws and requirements of the State in which such item or service is furnished in deviating from the guideline; acted in the best interest of the individual receiving the item or service; and acted in a manner consistent with the individual’s wishes.
An individual’s treating physician or other health care professional authorized to exercise independent professional judgment in implementing a patient’s medical or nursing care plan in accordance with the scope of practice, licensure, and other law of the State where items and services are to be furnished may override practice standards established pursuant to section 201(a) or practice guidelines described in paragraph (1), including such standards and guidelines that are implemented by a provider through the use of health information technology, such as electronic health record technology, clinical decision support technology, and computerized order entry programs.
An override described in subparagraph
(A)shall, in the professional judgment of such physician, nurse, or health care professional, be— consistent with such physician’s, nurse’s, or health care professional’s determination of medical necessity and appropriateness or nursing assessment; in the best interests of the individual; and consistent with the individual’s wishes.
Connectionstraces to 1
Traces to 1 document
U.S. Code
Citation graph
cites case law
Sec. 203
Exclusions and limitations
Cites 1Cited by 0 across 0 sources