Sec. 5.4. As used in this chapter, "medically necessary" means a health care service that a prudent health care provider would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or symptoms in a manner that is:
(1) in accordance with generally accepted standards of medical practice;
(2) clinically appropriate in terms of type, frequency, extent, site, and duration; and
(3) not primarily for:
(A) the economic benefit of the health plan or purchaser; or
(B) the convenience of the health plan, patient, treating physician, or other health care provider.