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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 1806 (March 30, 2024).

28 Pa. Code § 9.677. Requirements of definitions of ‘‘medical necessity.’’

§ 9.677. Requirements of definitions of ‘‘medical necessity.’’

 The definition of ‘‘medical necessity’’ shall be the same in the plan’s provider contracts, enrollee contracts and other materials used to evaluate appropriateness and to determine coverage of health care services. The definition shall comply with the HMO Act, the PPO Act, Act 68 and this chapter.

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