---
kind: "section"
citation: "42 C.F.R. § 405.925"
title: "42"
number: "405.925"
heading: "Decisions of utilization review committees."
url: "https://uscodex.org/cfr/42/405.925"
---

# §405.925. Decisions of utilization review committees.

- (a) **General rule.** A decision of a utilization review committee is a medical determination by a staff committee of the provider or a group similarly composed and does not constitute a determination by the Secretary within the meaning of [section 1869](/cfr/42/1869.md) of the Act. The decision of a utilization review committee may be considered by CMS along with other pertinent medical evidence in determining whether or not an individual has the right to have payment made under Part A of title XVIII.
- (b) **Applicability under the prospective payment system.** CMS may consider utilization review committee decisions related to inpatient hospital services paid for under the prospective payment system (see [part 412](/cfr/42/part412.md) of this chapter) only as those decisions concern:
  - (1) The appropriateness of admissions resulting in payments under subparts [D](/cfr/42/subpartD.md), [E](/cfr/42/subpartE.md) and G of [part 412](/cfr/42/part412.md) of this chapter.
  - (2) The covered days of care involved in determinations of outlier payments under [§ 412.80(a)(1)(i)](/cfr/42/412.80.md?p=a-1-i) of this chapter; and
  - (3) The necessity of professional services furnished in high cost outliers under [§ 412.80(a)(1)(ii)](/cfr/42/412.80.md?p=a-1-ii) of this chapter.

## Notes

### Amendments

[48 FR 39831, Sept. 1, 1983. Redesignated at 77 FR 29028, May 16, 2012]

### Source

Source: 70 FR 11472, Mar. 8, 2005, unless otherwise noted.

### Authority

Authority: 42 U.S.C. 263a, 405(a), 1302, 1320b-12, 1395x, 1395y(a), 1395ff, 1395hh, 1395kk, 1395rr, and 1395ww(k).

### Amendments

[48 FR 39831, Sept. 1, 1983. Redesignated at 77 FR 29028, May 16, 2012]