4-5 Vt. Code R. 4:6 - Review by independent review organization under the Department of Financial Regulation regulations

“Review by independent review organization under the Department of Financial Regulation regulations”

(A) An independent review organization to which an independent external review has been assigned by the Department of Financial Regulation must conduct a full review to determine whether:

• The health care service at issue is medically necessary;
• The health insurer has limited the insured's selection of a health care provider in a manner inconsistent with any limits imposed by the insurance contract and any applicable laws and rules;
• The proposed health care treatment is experimental, investigational or a medically-appropriate off-label use of a drug; and
• The service as to which coverage is being denied relates to a preexisting condition for which no coverage is available under the insurance contract.

(I) A health insurer must not retaliate against an insured or provider for any activity related to independent external review.