10- 144 C.M.R. ch. 272, § VI-II
Prior authorized services through the C.C.S./C.S.H.N. Program are available for congenital or acquired diseases or conditions of the musculoskeletal system that requires corrective subspecialty medical, or surgical treatment as follows:
In the event of a pre-natal diagnosis, the family will be referred to the Coordinator of the in-state Cleft Lip and Palate Clinics administered by Coordinated Care Services for Children with Special Health Needs Program. Upon the child's arrival to a hospital for definitive care, the Coordinator of the Cleft Lip and Palate Clinic will provide a hospital or home-based visit with the family. The purpose of this visit is to provide information, facilitate application to the C.C.S./C.S.H.N. Program and referral to the Cleft Palate clinics for evaluation and development of a comprehensive plan of care. Cleft Lip and Palate Clinic, and
planning services are available to all children with cleft lip and palate and certain other craniofacial anomalies who are enrolled in the C.C.S./C.S.H.N. Program, without regard to income. There are two types of clinics:
) provides a comprehensive evaluation of each child;
) clinic team develops a comprehensive plan of care that stipulates what needs to be done; outlines the time frames and recommended sequence of services;
) clinic team consists of: a pediatrician, plastic surgeon, prosthodontist, oral surgeon, otolaryngologist, pediatric dentist, orthodontist, geneticist, audiologist, speech/language pathologist, medical social work consultant, and a clinic coordinator.
For income eligible children, the C.C.S./C.S.H.N. Program will pre-authorize payment for the subspecialty medical and dental components of care recommended by the Cleft Palate Clinic team or specific subspecialty treatment by the prior authorized subspecialist as follows:
surgery and related hospitalization costs; office visits with the appropriate subspecialist to include ENT care; laboratory tests, x-rays and other imaging studies, prostheses and replacements; consultation with an approved feeding team which shall include a speech language pathologist, occupational therapist and registered dietitian; orthodontics to include bracing and appliances; routine and restorative dental care; genetic consultation and appropriate genetic studies through a MCH grant funded and approved in-state genetics program and specified in the recommendations of the Cleft Palate Clinic team; audiological evaluations with a Maine licensed audiologist if recommended; and/or speech/language therapy evaluation and treatment for pre-schoolers with a Maine licensed speech/language pathologist as defined for length and frequency in Chapter VI, Secion X, p. 41-44. Therapy is also available on a trial basis as part of a planned evaluation in consultation with the pre-authorized plastic surgeon to determine a child's need for further surgery.For those children with congenital or acquired cranio-facial anomalies, such as but not limited to, Aperts, Crouzon's, Treacher-Collins, Pierre-Robin syndrome and craniosynostosis who are referred by their primary care providers or a newborn nursery for subspecialty evaluation and/or treatment, the C.C.S./C.S.H.N. Program will refer to the Cleft Lip and Palate Clinic where appropriate and pre-authorize payment for:
a diagnostic evaluation by the appropriate subspecialist; surgical components of the plan of care and related hospitalization costs upon receipt of the report of evaluation; office visits with the appropriate subspecialist to include related tests; and/or prostheses and replacements; consultation with an approved feeding team which shall include a speech language pathologist, occupational therapist and registered dietitian if requested by the cleft lip and palate clinic team or the treating subspecialist; and/or occupational, physical and or speech language therapy for preschoolers as outlined in Chapter VI, Section X, p. 41-44.For those children who are referred by their primary care provider for subspecialty evaluation and/or treatment, the C.C.S./C.S.H.N. Program will pre-authorize payment for:
diagnostic evaluation or consultation with a pediatric rheumatologist or a rheumatologist with demonstrated pediatric experience; office visits with the rheumatologist upon receipt of the report of the evaluation; consultation and/or office visits with an orthopedist and/or ophthalmologist as referred by the rheumatologist and included in the plan of care; corrective surgery and related hospitalization costs; laboratory tests, x-rays and other imaging studies; medications as prescribed by the treating subspecialist; ophthalmologic procedures; and/or physical and/or occupational therapy consultations as recommended by the rheumatologist or orthopedist for the purpose of maximizing function, limited to three (3) units per month for a period of up to six (6) months.For those children who are referred by their primary care provider for subspecialty orthopedic evaluation and/or treatment of congenital or acquired disorders of the musculoskeletal system and orthopedic aspects of neuromuscular disease the C.C.S./C.S.H.N. Program will pre-authorize payment for:
a diagnostic evaluation by a pediatric orthopedist; surgical components of the plan of care and related hospitalization costs upon receipt of the report of the evaluation; office visits with the pediatric orthopedist; laboratory tests, x-rays and other imaging studies; corrective splints and braces for rehabilitative purposes; prostheses and replacements as recommended by the orthopedist; first pair of orthopedic shoes following surgery or serial casting; and/or occupational and physical therapy for preschoolers as outlined in Chapter VI, Section X, p. 41-44.NON COVERED ORTHOPEDIC SERVICES: treatment of genu varum and genu valgum; treatment of tibial torsion for children prior to the age of eight.
10- 144 C.M.R. ch. 272, § VI-II