In Union Labor Life Ins. Co. v. Pireno (1982) 458 U.S. 119, a chiropractor challenged an insurer's use of a peer review panel to determine which claims for chiropractic care the insurer would pay. The insurer defended by claiming that the use of a peer review committee was exempt from the antitrust laws as part of the business of insurance. ( Pireno, supra, 458 U.S. 119, 122.) The court held that the use of peer review to determine whether to pay claims was not the "business of insurance" within the scope of McCarran-Ferguson, and hence not exempt from the antitrust laws. Pireno distilled from Group Life & Health Ins. Co. v. Royal Drug Co. (1979) the "three criteria relevant in determining whether a particular practice is part of the 'business of insurance' exempted from the antitrust laws by 15 United States Code section 1012(b)." ( Pireno, supra, 458 U.S. at p. 129.) "First, whether the practice has the effect of transferring or spreading a policyholder's risk; second, whether the practice is an integral part of the policy relationship between the insurer and the insured; and third, whether the practice is limited to entities within the insurance industry." (Ibid.) In Pireno, however, the court cautioned that, "none of these criteria is necessarily determinative in itself." (Pireno, supra, 458 U.S. at p. 129 102 S. Ct. at p. 3009.) Applying the criteria to the peer review practice, the court determined that the practice did not spread risk, since the transfer of risk occurred when the policy was issued, and the peer review process was "logically and temporally unconnected to the transfer of risk." (Pireno, supra, 458 U.S. at p. 130.) The court also determined that peer review did not involve an integral part of the policy relationship between the insurer and its insured, nor was it limited to entities within the insurance industry, since the chiropractors performing the review were neither insureds nor within the insurance industry. (Id. at pp. 131-132 102 S. Ct. at pp. 3009-3010.)