If an initial determination involved a decision regarding the medical necessity of an item or service, the QIC reconsideration must involve consideration by a panel of physicians or appropriate healthcare professionals, and must be based on clinical experience, the patient medical records, and medical, technical, and scientific evidence on record. Where the claim involves physician services, the reviewing professional must be a physician. However, the physician reviewer need not be in the same specialty as the physician whose claims have been denied..
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