Ariz. Admin. Code § 9-22-1303

Current through Register Vol. 30, No. 43, October 25, 2024

Section R9-22-1303 - Medical Eligibility

The following lists identify those medical condition(s) that do qualify for CRS services as well as those that do not qualify for CRS services. The list of condition(s) that qualify for a CRS Designation is all inclusive. The list of condition(s) that do not qualify for a CRS Designation is not an all-inclusive list.

1. Cardiovascular System

a. CRS condition(s) that qualify for CRS medical eligibility:

i. Arrhythmia,

ii. Arteriovenous fistula,

iii. Cardiomyopathy,

iv. Conduction defect,

v. Congenital heart defect other than isolated small Ventricular Septal Defects (VSD), Patent Ductus Arteriosus (PDA), Atrial Septal Defects (ASD),

vi. Coronary artery and aortic aneurysm,

vii. Renal vascular hypertension,

viii. Rheumatic heart disease, and

ix. Valvular disorder.

b. Condition(s) not medically eligible for CRS:

i. Arteriovenous fistula that is not expected to cause cardiac failure or threaten loss of function;

ii. Benign heart murmur;

iii. Branch artery pulmonary stenosis;

iv. Essential hypertension;

v. Patent foramen ovale (PFO);

vi. Peripheral pulmonary stenosis;

vii. Postural orthopedic tachycardia; and

viii. Premature atrial, nodal or ventricular contractions that are of no hemodynamic significance.

2. Endocrine system:

a. CRS condition(s) that qualify for CRS medical eligibility:

i. Addison's disease,

ii. Adrenogenital syndrome,

iii. Cystic fibrosis (including atypical cystic fibrosis),

iv. Diabetes insipidus,

v. Hyperparathyroidism,

vi. Hyperthyroidism,

vii. Hypoparathyroidism, and

viii. Panhypopituitarism.

b. Condition(s) not medically eligible for CRS

i. Diabetes mellitus,

ii. Hypopituitarism associated with a malignancy and requiring treatment of less than 90 days,

iii. Isolated growth hormone deficiency, and

iv. Precocious puberty.

3. Genitourinary system medical condition(s):

a. CRS condition(s) that qualify for CRS medical eligibility:

i. Ambiguous genitalia,

ii. Bladder extrophy,

iii. Deformity and dysfunction of the genitourinary system secondary to trauma 90 days or more after the trauma occurred,

iv. Ectopic ureter,

v. Hydronephrosis, that is not resolved with antibiotics,

vi. Polycystic and multicystic kidneys,

vii. Pyelonephritis when treatment with drugs or biologicals has failed to cure or ameliorate and surgical intervention is required,

viii. Ureteral stricture, and

ix. Vesicoureteral reflux, at a grade 3 or higher.

b. Condition(s) not medically eligible for CRS:

i. Enuresis,

ii. Hydrocele,

iii. Hypospadias,

iv. Meatal stenosis,

v. Nephritis, infectious or noninfectious,

vi. Nephrosis,

vii. Phimosis, and

viii. Undescended testicle.

4. Ear, nose, or throat medical condition(s):

a. CRS condition(s) that qualify for CRS medical eligibility:

i. Cholesteatoma,

ii. Congenital/Craniofacial anomaly that is functionally limiting,

iii. Deformity and dysfunction of the ear, nose, or throat secondary to trauma, 90 days or more after the trauma occurred,

iv. Mastoiditis that continues 90 days or more after the first diagnosis of the condition,

v. Microtia that requires multiple surgical interventions,

vi. Neurosensory hearing loss, and

vii. Significant conductive hearing loss due to an anomaly in one ear or both ears equal to or greater than a pure tone average of 30 decibels that despite medical treatment, requires a hearing aid.

b. Condition(s) not medically eligible for CRS:

i. A craniofacial anomaly that is not functionally limiting,

ii. Adenoiditis,

iii. Cranial or temporal mandibular joint syndrome,

iv. Hypertrophic lingual frenum,

v. Isolated preauricular tag or pit,

vi. Nasal polyp,

vii. Obstructive apnea,

viii. Perforation of the tympanic membrane,

ix. Recurrent otitis media,

x. Simple deviated nasal septum,

xi. Sinusitis,

xii. Tonsillitis, and

xiii. Uncontrolled salivation.

5. Musculoskeletal system medical condition(s):

a. CRS condition(s) that qualify for CRS medical eligibility:

i. Achondroplasia,

ii. Arthrogryposis (multiple joint contractures),

iii. Bone infection that continues 90 days or more after the initial diagnosis,

iv. Chondrodysplasia,

v. Chondroectodermal dysplasia,

vi. Clubfoot,

vii. Collagen vascular disease, including but not limited to, ankylosis spondylitis, polymyositis, dermamyositis, polyarteritis nodosa, psoriatic arthritis, scleroderma, rheumatoid arthritis and lupus,

viii. Congenital or developmental cervical spine abnormality,

ix. Congenital spinal deformity,

x. Diastrophic dysplasia,

xi. Enchondromatosis,

xii. Femoral anteversion and tibial torsion,

xiii. Fibrous dysplasia,

xiv. Hip dysplasia,

xv. Hypochondroplasia,

xvi. Joint infection that continues 90 days or more after the initial diagnosis,

xvii. Juvenile rheumatoid arthritis,

xviii. Kyphosis (Scheurmann's Kyphosis) 50 degrees or over,

xix. Larsen syndrome,

xx. Leg length discrepancy of two centimeters or more,

xxi. Legg-Calve-Perthes disease,

xxii. Limb amputation or limb malformation,

xxiii. Metaphyseal and epiphyseal dysplasia,

xxiv. Metatarsus adductus,

xxv. Muscular dystrophy,

xxvi. Orthopedic complications of hemophilia,

xxvii. Osgood Schlatter's disease that requires surgical intervention,

xxviii. Osteogenesis imperfecta,

xxix. Rickets,

xxx. Scoliosis when 25 degrees or greater, or when there is a need for bracing or surgery,

xxxi. Seronegative spondyloarthropathy such as Reiters, psoriatic arthritis, and ankylosing spondylitis,

xxxii. Slipped capital femoral epiphysis,

xxxiii. Spinal muscle atrophy,

xxxiv. Spondyloepiphyseal dysplasia, and

xxxv. Syndactyly.

b. Condition(s) not medically eligible for CRS:

i. Back pain with no structural abnormality,

ii. Benign bone tumor,

iii. Bunion,

iv. Carpal tunnel syndrome,

v. Deformity and dysfunction secondary to trauma or injury,

vi. Ehlers Danlos,

vii. Flat foot,

viii. Fracture,

ix. Ganglion cyst,

x. Ingrown toenail,

xi. Kyphosis under 50 degrees,

xii. Leg length discrepancy of less than two centimeters at skeletal maturity,

xiii. Polydactyly without bone involvement,

xiv. Popliteal cyst,

xv. Trigger finger, and

xvi. Varus and valgus deformities.

6. Gastrointestinal system medical condition(s):

a. CRS condition(s) that qualify for CRS medical eligibility:

i. Anorectal atresia,

ii. Biliary atresia,

iii. Cleft lip,

iv. Cleft palate,

v. Congenital atresia, stenosis, fistula, or rotational abnormalities of the gastrointestinal tract,

vi. Deformity and dysfunction of the gastrointestinal system secondary to trauma, 90 days or more after the trauma occurred,

vii. Diaphragmatic hernia,

viii. Gastroschisis,

ix. Hirschsprung's disease,

x. Omphalocele, and

xi. Tracheoesophageal fistula.

b. Condition(s) not medically eligible for CRS:

i. Celiac disease,

ii. Crohn's disease,

iii. Hernia other than a diaphragmatic hernia,

iv. Intestinal polyp,

v. Malabsorption syndrome, also known as short bowel syndrome,

vi. Pyloric stenosis,

vii. Ulcer disease, and

viii. Ulcerative colitis.

7. Nervous system medical condition(s):

a. CRS condition(s) that qualify for CRS medical eligibility:

i. Benign intracranial tumor,

ii. Benign intraspinal tumor,

iii. Central nervous system degenerative disease,

iv. Central nervous system malformation or structural abnormality,

v. Cerebral palsy,

vi. Craniosynostosis requiring surgery,

vii. Deformity and dysfunction secondary to trauma in an individual that continues 90 days or more after the incident,

viii. Hydrocephalus,

ix. Muscular dystrophy or other myopathy,

x. Myelomeningocele, also known as spina bifida,

xi. Myoneural disorder, including but not limited to, amyotrophic Lateral Sclerosis or ALS, myasthenia gravis, Eaton-Lambert syndrome, muscular dystrophy, troyer sclerosis, polymyositis, dermamyositis, progressive bulbar palsy, polio,

xii. Neurofibromatosis,

xiii. Neuropathy/polyneuropathy, hereditary or idiopathic,

xiv. Residual dysfunction that continues 90 days or more after a vascular accident, inflammatory condition, or infection of the central nervous system,

xv. Residual dysfunction that continues 90 days or more after near drowning,

xvi. Residual dysfunction that continues 90 days or more after the spinal cord injury, and

xvii. Uncontrolled seizure disorder, in which there have been more than two seizures with documented compliance of one or more medications.

b. Condition(s) not medically eligible for CRS:

i. Central apnea secondary to prematurity,

ii. Febrile seizures,

iii. Headaches,

iv. Near sudden infant death syndrome,

v. Plagiocephaly, and

vi. Spina bifida occulta.

8. Ophthalmology:

a. CRS condition(s) that qualify for CRS medical eligibility:

i. Cataracts,

ii. Disorder of the iris, ciliary bodies, retina, lens, or cornea,

iii. Disorder of the optic nerve,

iv. Glaucoma,

v. Non-malignant enucleation and post-enucleation reconstruction, and

vi. Retinopathy of prematurity.

b. Condition(s) not medically eligible for CRS:

i. Astigmatism,

ii. Ptosis,

iii. Simple refraction error, and

iv. Strabismus.

9. Respiratory system medical condition(s):

a. CRS condition(s) that qualify for CRS medical eligibility:

i. Anomaly of the larynx, trachea, or bronchi that requires surgery, and

ii. Nonmalignant obstructive lesion of the larynx, trachea, or bronchi.

b. Condition(s) not medically eligible for CRS:

i. Allergies,

ii. Asthma,

iii. Bronchopulmonary dysplasia,

iv. Chronic obstructive pulmonary disease,

v. Emphysema, and

vi. Respiratory distress syndrome.

10. Dermatological system medical condition(s):

a. CRS condition(s) that qualify for CRS medical eligibility:

i. A burn scar that is functionally limiting,

ii. A hemangioma that is functionally limiting that requires laser or surgery,

iii. Complicated nevi requiring multiple procedures,

iv. Cystic hygroma such as lymphangioma, and

v. Malocclusion that is functionally limiting.

b. Condition(s) not medically eligible for CRS:

i. A deformity that is not functionally limiting,

ii. Ectodermal dysplasia,

iii. Isolated malocclusion that is not functionally limiting,

iv. Pilonidal cyst,

v. Port wine stain,

vi. Sebaceous cyst,

vii. Simple nevi, and

viii. Skin tag.

11. Metabolic CRS condition(s) that qualify for CRS medical eligibility:

a. Amino acid or organic acidopathy,

b. Biotinidase deficiency,

c. Homocystinuria,

d. Inborn error of metabolism,

e. Maple syrup urine disease,

f. Phenylketonuria, and

g. Storage disease.

12. Hemoglobinopathies CRS condition(s) that qualify for CRS medical eligibility:

a. Sickle cell anemia, and

b. Thalassemia.

13. Additional medical/behavioral condition(s) which are not medically eligible for CRS:

a. Allergies,

b. Anorexia nervosa or obesity,

c. Attention deficit disorder,

d. Autism,

e. Cancer,

f. Depression or other mental illness,

g. Developmental delay,

h. Dyslexia or other learning disabilities,

i. Failure to thrive,

j. Hyperactivity, and

k. Immunodeficiency, such as AIDS and HIV.

Ariz. Admin. Code § R9-22-1303

Adopted effective September 9, 1998 (Supp. 98-3). Amended by final rulemaking at 6 A.A.R. 3317, effective August 7, 2000 (Supp. 00-3). Section repealed by final rulemaking at 10 A.A.R. 808, effective April 3, 2004 (Supp. 04-1). Section made by exempt rulemaking at 18 A.A.R. 2074, effective August 1, 2012 (Supp. 12-3). New section made by final rulemaking at 19 A.A.R. 2954, effective November 10, 2013. Amended by Final rulemaking at 21 A.A.R. 2022, effective 10/1/2015. Amended by final rulemaking at 24 A.A.R. 2855, effective 11/16/2018.