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The treating doctor rule involves the authorized principle that the treating physician, who has examined the affected person and is most accustomed to the affected person’s condition, is in the best position to make medical necessity determinations. The treating physician rule, as adopted by some courts, displays that the treating physician’s willpower that a service is medically obligatory is binding until contradicted by substantial proof, and is entitled to some further weight, even when contradicted by substantial proof, because the treating doctor is inherently more acquainted with the affected person’s medical condition. As noted above, RACs make the most of the services of registered nurses (fairly than physician reviewers) to conduct critiques relating to medical necessity. Suppliers and suppliers should reference the treating physician rule to show that the treating doctor’s medical judgment as to the medical necessity of the services offered ought to be given deference.

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