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The treating physician rule involves the authorized precept that the treating doctor, who has examined the affected person and is most familiar with the patient’s condition, is in one of the best place to make medical necessity determinations. The treating physician rule, as adopted by some courts, reflects that the treating doctor’s determination that a service is medically crucial is binding except contradicted by substantial proof, and is entitled to some further weight, even if contradicted by substantial proof, as a result of the treating doctor is inherently extra familiar with the affected person’s medical condition. As famous above, RACs utilize the services of registered nurses (relatively than doctor reviewers) to conduct evaluations concerning medical necessity. Suppliers and suppliers ought to reference the treating doctor rule to exhibit that the treating physician’s medical judgment as to the medical necessity of the services offered needs to be given deference.
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