67:16:01:06.02Covered services must be medically

necessary. Services covered under this article must be medically necessary. To be medically necessary, the covered service must meet the following conditions: (1) It is consistent with the recipient's symptoms, diagnosis, condition, or injury; (2) It is recognized as the prevailing standard and is consistent with generally accepted professional medical standards of the provider's peer group; (3) It is provided in response to a life-threatening condition; to treat pain, injury, illness, or infection; to treat a condition that could result in physical or mental disability; or to achieve a level of physical or mental function consistent with prevailing community standards for diagnosis or condition; (4) It is not furnished primarily for the convenience of the recipient or the provider; and (5) There is no other equally effective course of treatment available or suitable for the recipient requesting the service which is more conservative or substantially less costly.

Source: 17 SDR 184, effective June 6, 1991.