Binding law — in force
Only a clinical peer makes a medical-necessity adverse determination or decides an appeal (Indiana SEA 480)
From 2025-07-01, a utilization review entity must ensure that every adverse determination based on medical necessity (a decision to deny, reduce or terminate coverage of a health care service, IC 27-1-37.5-1.5) is made, and every appeal reviewed and decided, by a clinical peer under the clinical direction of a medical director who is an Indiana-licensed physician (IC 27-1-37.5-20(a)); an appeal may not be decided by a peer with a financial interest or who made the determination (20(b)), and an adverse determination must give specific reasons and suggested alternatives (23(c)). The chapter never mentions AI: it binds whatever tool proposes the outcome. Detect model or scoring output that sets an adverse determination with no clinical-peer decision.
in-sb480.clinical-peer-makes-adverse-determinations · IC 27-1-37.5-20(a) · official source · jurisdictions: US-IN