(a) This section applies to: (1) insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies that are issued or delivered in the State; and (2) health maintenance organizations that provide hospital, medical, and surgical benefits to individuals or groups under contracts that are issued or delivered in the State. (b) (1) Subject to paragraph (2) of this subsection, a policy or plan subject to this section shall include, under the family member coverage, coverage for amino acid–based elemental formula, regardless of delivery method, for the diagnosis and treatment of: (i) Immunoglobulin E and non–Immunoglobulin E mediated allergies to multiple food proteins; (ii) severe food protein induced enterocolitis syndrome; (iii) eosinophilic disorders, as evidenced by the results of a biopsy; and (iv) impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract. (2) Subject to paragraph (3) of this subsection, the coverage required under paragraph (1) of this subsection is required ptive surface, functional length, and motility of the gastrointestinal tract. (2) Subject to paragraph (3) of this subsection, the coverage required under paragraph (1) of this subsection is required if the ordering physician has issued a written order stating that the amino acid–based elemental formula is medically necessary for the treatment of a disease or disorder listed in paragraph (1) of this subsection. (3) In accordance with Subtitle 10A of this title, a private review agent, acting on behalf of an insurer, nonprofit health service plan, or health maintenance organization, may review the ordering physician’s determination of the medical necessity of the amino acid–based elemental formula for the treatment of a disease or disorder listed in paragraph (1) of this subsection.
Maryland Legal Code