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-III - CARDIO-RESPIRATORY 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 chronic cardiac and/or respiratory
					 diseases that require subspecialty medical or surgical treatment as
					 follows:
A.
Cardiac
				  Defects
:
For those children who are referred by their primary care
					 provider or a newborn nursery for subspecialty evaluation and/or medical or
					 surgical treatment for congenital heart disease, acquired cardiac problems such
					 as, but not limited to, rheumatic fever, Kawasaki disease, cardiomyopothies and
					 arrhythmia, the C.C.S./C.S.H.N. Program will pre-authorize payment for:
diagnostic evaluation with a pediatric
						cardiologist;
											 office visits to the pediatric cardiologist, related
						tests and procedures as recommended by the pediatric cardiologist upon receipt
						of the report of the evaluation;
											 surgical components of the plan of care upon receipt
						of the report of the evaluation and related hospitalization;
											medications and prophylactic antibiotics as
						prescribed by the pediatric cardiologist;
											routine preventive dental care up to $150/year at
						State rates of reimbursement; and/or
											 annual re-evaluation services for up to three (3)
						years for those children who have achieved stabilization.
NON-COVERED CARDIAC SERVICES
: cardiac
					 transplants and neonatal intensive care.
B.
Respiratory
				  Diseases
1.
Asthma
For those children who because of severe asthma, have a
					 history of emergency room visits or hospitalization, and/or experience
					 significant functional limitations which interfere with their daily activities
					 and 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:
) diagnostic evaluation with a pediatric pulmonologist or
					 pediatric allergist. Other pediatricians with demonstrated experience in the
					 treatment of asthma through specialized training and emphasis on this condition
					 in their clinical practice may be approved as a provider for the purposes of
					 this section upon registration with and approval from the Physician supervisor
					 in charge of the medical component of C.C.S./C.S.H.N. services;
) subspecialty office visits upon receipt of the evaluation
					 report;
) medications for the treatment of asthma as prescribed by
					 the treating subspecialist;
) antibiotics for pulmonary infections associated with
					 exacerbation of asthma;
) durable medical equipment that is medically necessary to
					 deliver medication to the child's lungs and measure the drug's
					 effectiveness;
) asthma management education at a Medicaid-approved site;
					 and/or
) retroactive coverage for emergency out-patient or
					 in-patient treatment of asthma 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.