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If an preliminary determination concerned a choice relating to the medical necessity of an item or service, the QIC’s reconsideration should involve consideration by a panel of physicians or acceptable healthcare professionals, and should be based mostly on medical experience, the affected person’s medical data, and medical, technical, and scientific evidence on record. The place the claim entails physician companies, the reviewing professional must be a physician. Nevertheless, the doctor reviewer needn’t be in the same specialty as the physician whose claims have been denied.
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