Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-90 - Physician Services › Subsection 144-101-II-90.05 - RESTRICTED SERVICES

Current through 2024-29, July 17, 2024
90.05-1
Services Covered With Prior Authorization (PA)
Some services and procedures require prior authorization
						for MaineCare to provide payment. MaineCare lists provider procedures, the
						amount paid for the service, and whether the procedure requires prior
						authorization on the MaineCare Services website. When new procedure codes are
						added to MaineCare reimbursement, MaineCare may require prior authorization.
						Only some of the categories of procedures requiring prior authorization are
						detailed in this section; providers are responsible for checking each procedure
						code on the OMS website to determine whether it is covered and whether it
						requires prior authorization. Providers can find procedures requiring PA and PA
						requirements at: https://mainecare.maine.gov. In cases where the criteria are
						not met, the provider or member may submit additional supporting evidence such
						as medical documentation, to demonstrate that the requested service is
						medically necessary.
A. MaineCare
					 covers the following services only when the Department has granted prior
					 authorization using the criteria outlined below:
1.
Out-of-State Services
All services, including but not limited to diagnosis,
						evaluation or treatment to be provided outside the State of Maine require prior
						authorization. (See MBM, Chapter I, Section 1.14 for policies and procedures
						regarding out-of-state services). Use of out-of-state diagnostic services,
						excluding lab or radiology tests by enrolled MaineCare providers, requires
						prior authorization. MaineCare providers referring out-of-state services are
						responsible for assuring that services are referred to a MaineCare provider.
						Providers cannot bill the member unless the member was advised at the
						provider's office prior to provision of the service that the service may not be
						covered by MaineCare and that the member may be responsible for the services.
						Prior notification must be documented in the member's record.
2.
Vagus Nerve Stimulation
MaineCare covers medically necessary vagus nerve
						stimulation for treatment of partial onset seizures for adults and children
						over twelve (12) years of age when clinically appropriate medications are
						refractory.
3.
Orthognathic Surgery
Orthognathic surgery requires prior authorization, and is
						not covered for cosmetic purposes. Orthognathic surgery is only covered for
						medically necessary indications such as:
i. Jaw and craniofacial deformities causing
					 significant functional impairment for the following clinical indications:
a. repair or correction of a congenital
					 anomaly that is present at birth; or
b. restoration and repair of function
					 following treatment for a significant accidental injury, infection, or
					 tumor.
ii.
					 Anteroposterior, vertical, or transverse discrepancies or asymmetries that are
					 two or more standard deviations from published norms and that cause one or more
					 of the following documented functional conditions:
a. difficulty swallowing and/or choking, or
					 ability to chew only soft or liquid food for at least four (4) months; or
b.  speech abnormalities
					 determined by a speech pathologist or therapist; or malnutrition related to the
					 inability to masticate, documented significant weight loss over four (4) months
					 and a low serum albumin related to malnutrition; or
c. intra-oral trauma while chewing related to
					 malocclusion; or
d. significant
					 obstructive sleep apnea not responsive to treatment.
Documentation must include, but is not limited to, study
						models with appropriate bite registration, intra-oral and extra-oral
						photographs, and cephalometric x-ray.
4.
Gender Dysphoria Related
					 Surgery
Gender dysphoria related surgery requires prior
						authorization and will be reimbursed by MaineCare, based on the following
						standards:
i. The member has letters
					 from two qualified Maine licensed health professionals who have independently
					 assessed the member and are referring the member for surgery. The letters must
					 establish that the member has gender dysphoria, has no other significant
					 medical or mental health condition that would be contraindicated to surgery,
					 and that the surgery is medically necessary for the member.
ii. The determination of medically necessary
					 may use criteria based on national standards, such as the Standards of Care
					 (SOC) of the World Professional Association for Transgender Health
					 (WPATH).