10- 144 C.M.R. ch. 272, § VI-III
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:
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.
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.
NON COVERED ASTHMA SERVICES: Treatment of rhinitis or allergy medications.
For those children with but not limited to congenital anomalies of the respiratory tract and broncho pulmonary dysplasia, who are referred by their primary care provider or newborn nursery for subspecialty evaluation and/or medical or surgical treatment, the C.C.S./C.S.H.N. Program will pre-authorize payment for:
) diagnostic evaluation with a pediatric pulmonologist or approved pulmonology clinic;
) office visits to the pediatric pulmonologist, related tests and procedures as recommended by the pediatric pulmonologist 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; and
) medications and prophylactic antibiotics as prescribed by the pediatric pulmonologist.
10- 144 C.M.R. ch. 272, § VI-III