IC 27-1-37.5-1.5: "Adverse determination"

Sec. 1.5. As used in this chapter, "adverse determination" means a decision by a utilization review entity to deny, reduce, or terminate benefit coverage of a health care service furnished or proposed to be furnished to a covered individual on the grounds that the health care service:

(1) is not medically necessary, appropriate, effective, or efficient;

(2) is not being provided in or at an appropriate health care setting or level of care; or

(3) is experimental or investigational.