Clinical Rationale definition
Clinical Rationale means a statement or other documentation that taken together provides additional clarification of the clinical basis for a non-Certification determination. The Clinical Rationale should relate the non-Certification determination to the worker's condition or treatment plan, and must include a detailed basis for denial or non-Certification of the proposed treatment to give the provider or patient a sufficient basis for a decision to pursue an Appeal. Clinical Rationale must include specific reference to any applicable provisions of the Mississippi Workers' Compensation Medical Fee Schedule, which allegedly support the determination of the reviewer, or a statement attesting to the fact that no such provision(s) exists in the Fee Schedule.