10- 144 C.M.R. ch. 272, § VI-IV
Prior authorized services through the C.C.S./C.S.H.N. Program are available for chronic metabolic or endocrine conditions that require subspecialty medical or surgical treatment as follows:
Eligibility is restricted to those children who are referred to the C.C.S./C.S.H.N. Program for diagnostic evaluation and treatment through one of the three out-patient hospital based clinic services affiliated with Maine Medical Center, Portland; Eastern Maine Medical Center, Bangor; and Central Maine Medical Center, Lewiston. The team consists of a pediatrician, medical social worker, physical therapist, clinic coordinator, registered dietitian, public health nurse, and respiratory therapist. No assistance is offered for an evaluation by a private practitioner in his/her office. The C.C.S./C.S.H.N. Program will pre-authorize payment for the medical components of the plan of care recommended by the Cystic Fibrosis Clinic team as follows:
diagnostic evaluation and related tests at one of the identified Cystic Fibrosis Clinics; Cystic Fibrosis Clinic appointments; laboratory tests and antibiotic or respiratory therapy that includes nebulizers and medications; pancreatic replacement enzymes and vitamins; planned hospitalizations and related costs at the approved Cystic Fibrosis Clinic Center or at a center recommended by the prior authorized treating Cystic Fibrosis team; ear, nose and throat (ENT) care as recommended by the prior authorized treating Cystic Fibrosis Clinic team; a genetic consultation and appropriate genetic studies if indicated through an approved genetic program; diabetes as a complication of cystic fibrosis to include blood testing, insulin and supplies; and/or retroactive coverage for emergency out-patient or in-patient treatment of cystic fibrosis and its complications 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 CYSTIC FIBROSIS SERVICES: evaluation or treatment by a private practitioner in his/her office
For those children 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:
a diagnostic evaluation/consultation by a pediatric diabetes specialist, endocrinologist or through a pediatric out-patient diabetic clinic. This evaluation may include laboratory tests and related hospitalization costs; office visits with the pediatric diabetic specialist, endocrinologist or diabetic clinic visits upon receipt of the plan of care; blood sugar testing and other appropriate laboratory tests if ordered by the diabetes specialist or clinic and included in the plan of care; insulin and equipment to administer insulin as prescribed by the pediatric diabetes specialist; home testing equipment and supplies to monitor blood levels if prescribed by the pediatric diabetes specialist; medical nutrition therapy with a registered dietitian; diabetes education through an approved Pediatric Diabetes Education Program; and/or ophthalmological evaluation, as recommended by the treating diabetes specialist.For those children referred by their primary health care providers for an initial evaluation by a pediatric endocrinologist to confirm or rule out this deficiency, the C.C.S./C.S.H.N. Program will pre-authorize payment for a diagnostic evaluation only with a pediatric endocrinologist, payment may include laboratory tests, for said evaluation.
NON-COVERED GROWTH HORMONE SERVICES: growth hormone therapy, even if part of a diagnostic trial.
For those children with congenital metabolic disorders who have been tested, identified and referred through the Newborn Screening Program, the C.C.S./C.S.H.N. Program will pre-authorize payment for:
evaluation with an appropriate pediatric subspecialist for the development of a treatment plan; office visits with a pediatric subspecialist to include laboratory tests; clinic visits to an in-state metabolic clinic; medical nutrition consultation and subsequent therapy by a registered dietitian to include at minimum office visits with the dietitian every four (4) months as recommended by the treating subspecialist and upon receipt of the plan of care; metabolic formula not covered by any other source as prescribed by the treating subspecialist; special medical food for the clinical disorder not covered by any other source to include special modified low protein foods for children with inborn errors of metabolism as prescribed by the metabolic clinic or treating subspecialist and upon receipt of the plan of care; genetic consultation and appropriate genetic studies through an approved in-state MCH genetic program as requested by the treating subspecialist or metabolic clinic team; and/or psychometric testing every three years if requested by the treating subspecialist or the metabolic clinic team.10- 144 C.M.R. ch. 272, § VI-IV