2022 South Carolina Code of Laws
Title 38 - Insurance
Chapter 71 - Accident And Health Insurance
Section 38-71-144. Expedited external reviews of certain health benefit plan cancer diagnostic service denials.
(A) For purposes of this section:
(1) "Health benefit plan" means all individual and group health insurance policies and health maintenance organizations issued, delivered or renewed in this State, to include the State Health Plan, but otherwise not to include the administrative services performed on behalf of a self-funded plan subject to the Employee Retirement Income Security Act (ERISA) of 1974 or other plans exempted by Section 38-71-1920(9).
(2) "Stage four advanced, metastatic cancer" means cancer that has spread from the primary or original site of the cancer to nearby tissues, lymph nodes, or other areas or parts of the body.
(3) "Recognized diagnostic imaging service" means a diagnostic imaging service for the diagnosis and treatment of stage four advanced, metastatic cancer for which the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology provide a uniform consensus that the proposed use of the diagnostic imaging service is appropriate and is supported by peer-reviewed literature.
(B) If a health benefit plan that covers the treatment of stage four advanced, metastatic cancer denies a prior authorization request or a claim for a recognized diagnostic imaging service for a covered person's stage four advanced metastatic cancer based upon an adverse medical necessity determination, then the covered person shall have a right to an expedited external review in accordance with Section 38-71-1980.
HISTORY: 2022 Act No. 187 (H.3775), Section 1, eff May 16, 2022.
Editor's Note
2022 Act No. 187, Section 2, provides as follows:
"SECTION 2. This act takes effect upon approval by the Governor, and applies to health benefit plans issued, renewed, delivered, or entered into on or after the effective date of this act."
