Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 272 - COORDINATED CARE SERVICES FOR CHILDREN WITH SPECIAL HEALTH NEEDS › Chapter VI - CONDITIONS AND COMPONENTS OF CARE › Section 144-272-VI-I - NEUROSENSORY SYSTEM

Current through 2024-29, July 17, 2024
Prior authorized services through the C.C.S./C.S.H.N.
					 Program are available for congenital or acquired neurosensory conditions as
					 follows:
A.
Chronic Ear
				  Disease
For those children who are referred by their primary care
					 providers for subspecialty evaluation and/or surgical intervention, the
					 C.C.S./C.S.H.N. Program will pre-authorize payment for:
a diagnostic evaluation by an otolaryngologist (ENT
						Specialist). This evaluation may include a diagnostic hearing test by a Maine
						licensed audiologist;
											surgical components of the plan of care to include
						but not limited to tube placement, and otoplasty following receipt of the
						report of the evaluation;
											office visits with the otolaryngologist for up to two
						months following surgery;
											quarterly office visits for tube maintenance,
						thereafter, with the otolaryngologist as long as tubes are in place;
											medication as recommended by the otolaryngologist for
						acute infections related to blocked tubes if documentation is provided;
						and/or
											 repair of tympanic membrane perforations and
						follow-up.
B.
Hydrocephalus
For those children who are referred by a neonatal unit or
					 their primary care providers for pediatric neurological and neurosurgical
					 services, the C.C.S./C.S.H.N. Program will pre-authorize payment for:
diagnostic evaluations by a pediatric neurologist
						and/or neurosurgeon. This evaluation may include laboratory tests;
											 surgical components of the plan of care including
						shunt placements and revisions upon receipt of the report of the
						evaluation;
											 office visits with the appropriate subspecialist to
						include neurosurgical follow-up and related tests as needed; and/or
											 occupational, physical and/or speech language
						therapy for preschoolers as defined for frequency and length of therapy under
						Chapter VI, Section X, p. 41-44.
C.
Congenital Peripheral Nerve Injury
Upon referral of neonates with peripheral nerve injury, the
					 C.C.S./C.S.H.N. Program will pre-authorize payment for:
diagnostic evaluation by a pediatric orthopedist
						and/or neurologist. This evaluation may include x-rays, other imaging studies
						and nerve conduction studies as recommended by the treating
						subspecialist;
											 office visits with the subspecialist for children up
						to two (2) years of age upon receipt of the report of the
						evaluation;
											occupational and/or physical therapy evaluation and
						treatment with a Maine licensed therapist in accordance with Chapter VI,
						Section X, p. 41-44, if recommended by the treating subspecialist;
											 therapy consultations one (1) time per month;
						and/or
											splints as prescribed by the appropriate
						subspecialist.
D.
Myelodysplasia (Spina Bifida)
In the event of a pre-natal diagnosis, the family will be
					 referred to the Coordinator of an in-state Myelodysplasia Clinic which is
					 supported by Coordinated Care Services for Children with Special Health Needs
					 Program.
Upon the child's arrival at a hospital for definitive care
					 where a Myelodysplasia Clinic is located, a member of the clinic team will
					 provide a hospital based visit with the family regardless of the family's
					 financial resources. The intent of this hospital visit is to provide
					 information to the family, facilitate application to the C.C.S./C.S.H.N.
					 Program and referral to an in-state Myelodysplasia Clinic for evaluation and
					 development of a comprehensive plan of care.
For income eligible children, the C.C.S./C.S.H.N. Program
					 will pre-authorize payment for the medical components of care recommended by
					 the Myelodysplasia Clinic team or specific subspecialty treatment by the prior
					 authorized subspecialist as follows:
office visits with the appropriate
						subspecialist;
											 surgery and related hospitalization
						costs;
											 laboratory tests, x-rays, and other imaging studies;
						
											 medications as prescribed by the treating
						subspecialist;
											 urodynamic studies;
											 skilled nursing visits where indicated for education
						and training in bowel programs, catheterization and follow-up;
											 catheters, ostomy bags and supplies;
											 incontinence pants and liners after three years of
						age;
											 casting and bracing if prescribed by the pediatric
						orthopedist;
											 neurosurgical care to include emergency care for
						shunt malfunctions;
											 medical nutrition therapy with a registered
						dietitian;
											 occupational, physical and/or speech language
						therapy for preschoolers as defined for frequency and length or therapy under
						Chapter VI, Section X, p. 41-44; and
											 durable medical equipment as prescribed by the
						appropriate subspecialist;
E.
Ophthalmologic Disorders
Prior authorized services through the C.C.S./C.S.H.N.
					 Program are available for eye disorders that would progress to significant
					 visual impairment or binocular dysfunction if left untreated, and/or have a
					 corrected visual acuity of 20/40 or worse in the better eye. Examples of
					 conditions may include but are not limited to congenital eye problems, diseases
					 of the cornea and lid; refractive problems, optic nerve and retinal diseases,
					 cataracts, glaucoma, strabismus, amblyopia and uveitis:
For those children who are referred by their primary care
					 providers or optometrist for subspecialty evaluation or treatment, the
					 C.C.S./C.S.H.N. Program will pre-authorize payment for:
a diagnostic evaluation with an
						ophthalmologist;
											surgical components of the plan of care following
						receipt of the report of the evaluation to include surgery, laser treatment,
						and hospitalization.
cataract surgery: intra-ocular lenses, contact lenses or
					 glasses immediately following cataract surgery with replacements as medically
					 necessary upon written request of and where prescribed by the treating
					 ophthalmologist;*
office visits with the ophthalmologist to include
						related tests, treatment with glasses,* patching and medications where
						specifically recommended by the treating ophthalmologist and upon receipt of
						the report of the evaluation/plan of care.
*NOTE:
glasses must be pre-approved and
					 ordered through Coordinated Care Services For Children With Special Health
					 Needs. The C.C.S./C.S.H.N. Program will then authorize payment through a local
					 optometrist or optician who contracts with the State approved supplier.
NON-COVERED OPHTHALMOLOGIC SERVICES:
routine
					 primary eye care; annual eye examinations; vision training or therapy.
F.
Seizure
				  Disorders
For those children who are referred by their primary care
					 provider or by one of the C.C.S./C.S.H.N. Program funded Developmental
					 Evaluation Clinics, the C.C.S./C.S.H.N. Program will pre-authorize payment
					 for:
diagnostic evaluation with a pediatric neurologist.
						This evaluation may include x-rays, imaging studies, laboratory tests including
						EEG's;
											 office visits with a pediatric neurologist upon
						receipt of the plan of care;
											appropriate blood tests and drug levels;
											 medications for the seizure disorder as prescribed
						by the pediatric neurologist until the subspecialist advises that the seizures
						are controlled to the extent possible;
											 occupational, physical or speech language therapy
						evaluation and treatment for preschoolers with a Maine licensed therapist if
						recommended by the pediatric neurologist as described for length and frequency
						in Chapter VI, Section X, p. 41-44;
											 annual pediatric neurological evaluation while on
						medication if requested by the primary care provider, pediatric specialist or
						neurologist; and/or
											 retroactive coverage for emergency out-patient or
						in-patient treatment of seizure disorders will be considered after receipt and
						review of appropriate medical documentation and, if the parents notify
						C.C.S./C.S.H.N. within one week of the emergency.