10- 144 C.M.R. ch. 272, § VI-I
Prior authorized services through the C.C.S./C.S.H.N. Program are available for congenital or acquired neurosensory conditions as follows:
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.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.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.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;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.
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.10- 144 C.M.R. ch. 272, § VI-I