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-IV - METABOLIC/ENDOCRINE SYSTEM

Current through 2024-29, July 17, 2024
Prior authorized services through the C.C.S./C.S.H.N.
					 Program are available for chronic metabolic or endocrine conditions that
					 require subspecialty medical or surgical treatment as follows:
A.
Cystic Fibrosis
Eligibility is restricted to those children who are
					 referred to the C.C.S./C.S.H.N. Program for diagnostic evaluation and treatment
					 through one of the three out-patient hospital based clinic services affiliated
					 with Maine Medical Center, Portland; Eastern Maine Medical Center, Bangor; and
					 Central Maine Medical Center, Lewiston. The team consists of a pediatrician,
					 medical social worker, physical therapist, clinic coordinator, registered
					 dietitian, public health nurse, and respiratory therapist. No assistance is
					 offered for an evaluation by a private practitioner in his/her office. The
					 C.C.S./C.S.H.N. Program will pre-authorize payment for the medical components
					 of the plan of care recommended by the Cystic Fibrosis Clinic team as
					 follows:
diagnostic evaluation and related tests at one of the
						identified Cystic Fibrosis Clinics;
											 Cystic Fibrosis Clinic appointments;
											 laboratory tests and antibiotic or respiratory
						therapy that includes nebulizers and medications;
											pancreatic replacement enzymes and
						vitamins;
											 planned hospitalizations and related costs at the
						approved Cystic Fibrosis Clinic Center or at a center recommended by the prior
						authorized treating Cystic Fibrosis team;
											 ear, nose and throat (ENT) care as recommended by
						the prior authorized treating Cystic Fibrosis Clinic team;
											a genetic consultation and appropriate genetic
						studies if indicated through an approved genetic program;
											 diabetes as a complication of cystic fibrosis to
						include blood testing, insulin and supplies; and/or
											 retroactive coverage for emergency out-patient or
						in-patient treatment of cystic fibrosis and its complications will be
						considered after receipt and review of appropriate medical documentation and,
						if the parents notify Coordinated Care Services within one week of the
						emergency.
NON COVERED CYSTIC FIBROSIS SERVICES
:
					 evaluation or treatment by a private practitioner in his/her office
B.
Diabetes
For those children who are referred by their primary care
					 providers for subspecialty evaluation and/or treatment, the C.C.S./C.S.H.N.
					 Program will pre-authorize payment for:
a diagnostic evaluation/consultation by a pediatric
						diabetes specialist, endocrinologist or through a pediatric out-patient
						diabetic clinic. This evaluation may include laboratory tests and related
						hospitalization costs;
											 office visits with the pediatric diabetic
						specialist, endocrinologist or diabetic clinic visits upon receipt of the plan
						of care;
											 blood sugar testing and other appropriate laboratory
						tests if ordered by the diabetes specialist or clinic and included in the plan
						of care;
											 insulin and equipment to administer insulin as
						prescribed by the pediatric diabetes specialist;
											 home testing equipment and supplies to monitor blood
						levels if prescribed by the pediatric diabetes specialist;
											medical nutrition therapy with a registered
						dietitian;
											 diabetes education through an approved Pediatric
						Diabetes Education Program; and/or
											 ophthalmological evaluation, as recommended by the
						treating diabetes specialist.
C.
Idiopathic Growth Hormone Deficiency
For those children referred by their primary health care
					 providers for an initial evaluation by a pediatric endocrinologist to confirm
					 or rule out this deficiency, the C.C.S./C.S.H.N. Program will pre-authorize
					 payment for a diagnostic evaluation only with a pediatric endocrinologist,
					 payment may include laboratory tests, for said evaluation.
NON-COVERED GROWTH HORMONE SERVICES:
growth
					 hormone therapy, even if part of a diagnostic trial.
D.
Other Metabolic
				  Disorders
For those children with congenital metabolic disorders who
					 have been tested, identified and referred through the Newborn Screening
					 Program, the C.C.S./C.S.H.N. Program will pre-authorize payment for:
evaluation with an appropriate pediatric
						subspecialist for the development of a treatment plan;
											office visits with a pediatric subspecialist to
						include laboratory tests;
											clinic visits to an in-state metabolic
						clinic;
											medical nutrition consultation and subsequent therapy
						by a registered dietitian to include at minimum office visits with the
						dietitian every four (4) months as recommended by the treating subspecialist
						and upon receipt of the plan of care;
											metabolic formula not covered by any other source as
						prescribed by the treating subspecialist;
											special medical food for the clinical disorder not
						covered by any other source to include special modified low protein foods for
						children with inborn errors of metabolism as prescribed by the metabolic clinic
						or treating subspecialist and upon receipt of the plan of care;
											genetic consultation and appropriate genetic studies
						through an approved in-state MCH genetic program as requested by the treating
						subspecialist or metabolic clinic team; and/or
											psychometric testing every three years if requested
						by the treating subspecialist or the metabolic clinic team.