NAC442.784. Eligible medical conditions: Categories; identification.

     1. A client’s eligible medical condition will be assigned to one of the following categories to determine the extent of medical services that will be provided under the program:

     (a) Category 1 includes conditions:

          (1) Which require ambulatory or outpatient services only; and

          (2) For which an excellent prognosis is anticipated.

     (b) Category 2 includes conditions:

          (1) Which require ambulatory or outpatient services or limited inpatient care; and

          (2) For which a good prognosis and the prevention of disability or deterioration is anticipated if the condition is treated.

     (c) Category 3 includes conditions:

          (1) Which require prolonged outpatient treatment and frequent hospitalization with high morbidity if not treated; and

          (2) For which a fair prognosis is anticipated.

Ê For the purposes of this subsection, the prognosis must be based on an analysis of the client’s functional ability for the activities of daily living.

     2. The following conditions are eligible medical conditions:

     (a) Blood cell conditions, including, but not limited to:

          (1) Sickle-cell disease.

          (2) Thalassemia, major.

     (b) Cardiovascular conditions, including, but not limited to:

          (1) Acquired heart disease.

          (2) Arrhythmia.

          (3) Congenital malformations of the blood vessels.

          (4) Congenital malformations of the heart.

          (5) Hypertension.

          (6) Vascular occlusion.

     (c) Endocrinological conditions, including, but not limited to:

          (1) Adrenal dysfunction, including pseudohermaphroditism.

          (2) Diabetes mellitus, type 1 (insulin dependent).

          (3) Diabetes insipidus.

          (4) Thyroid dysfunction.

          (5) Pituitary dysfunction, including:

               (I) Hypogonadism; and

               (II) Dwarfism, if the client’s height is less than the third percentile, growth is less than 4 centimeters per year and bone age is more than 2 years behind chronological age.

     (d) Craniofacial anomalies, including, but not limited to:

          (1) Cleft lip and palate and medically necessary dental restoration required as a result of the cleft lip or palate.

          (2) Congenital facial abnormalities associated with chromosomal abnormalities or known syndromes or causing oral or motor dysfunction, or both.

          (3) Craniosynostosis.

     (e) Ear disorders, including, but not limited to:

          (1) Chronic mastoiditis or cholesteatoma.

          (2) Congenital malformations of the ear.

          (3) Congenital or acquired hearing loss.

     (f) Eye conditions, including, but not limited to:

          (1) Eye injuries involving poisoning or trauma. Such injuries will be covered from the time of injury if the potential for rehabilitation exists.

          (2) Cataracts.

          (3) Congenital herpes.

          (4) Glaucoma.

          (5) Keratoconus.

          (6) Ptosis, if it covers the pupil.

          (7) Strabismus that cannot be corrected with eyeglasses.

     (g) Gastrointestinal disorders, including, but not limited to:

          (1) Incarcerated hernia.

          (2) Intestinal obstruction or pseudo-obstruction.

          (3) Omphalocele and gastroschisis.

          (4) Pancreatitis, chronic.

          (5) Ulcerative colitis.

     (h) Genitourinary disorders, including, but not limited to:

          (1) Ambiguous genitalia.

          (2) Epispadias.

          (3) Hypospadias.

          (4) Incarcerated hernia.

          (5) Neurogenic bladder.

          (6) Obstructive uropathy.

          (7) Testicular torsion.

          (8) Undescended testicles.

          (9) Ureterocele.

          (10) Ureteropelvic junction (UPJ) obstruction.

          (11) Vesicoureteral reflux.

     (i) Metabolic disorders that are treatable inborn errors of metabolism, including, but not limited to:

          (1) Aminoaciduria.

          (2) Biotinidase deficiency.

          (3) Cystic fibrosis.

          (4) Galactosemia.

          (5) Glycogen storage disease.

          (6) Homocystinuria.

          (7) Maple syrup urine disease.

          (8) Phenylketonuria.

          (9) Tyrosinemia.

     (j) Neurological disorders, including, but not limited to:

          (1) Arachnoid cysts.

          (2) Brain injury or disease.

          (3) Seizure disorder.

          (4) Dermal sinus of the spine or cranium.

          (5) Guillain-Barre syndrome.

          (6) Hydrocephalus.

          (7) Intracranial neoplasms.

          (8) Meningocele.

          (9) Tethered cord syndrome (tight filum).

          (10) Spina bifida.

          (11) Spinal cord disease, including a ruptured disc and spinal fracture causing paraplegia.

     (k) Orthopedic conditions, including, but not limited to:

          (1) Amputated limbs, congenital or acquired.

          (2) Arthrosis.

          (3) Blount’s disease.

          (4) Osteomyelitis.

          (5) Complications of fractures, such as chronic infection, nonunion and avascular necrosis.

          (6) Congenital deformities of the arm, hand, hip, knee or foot.

          (7) Cysts.

          (8) Juvenile rheumatoid arthritis.

          (9) Osteochondrosis, including Legg-Perthes disease.

          (10) Scoliosis.

          (11) Tibial torsion that impairs ambulation.

          (12) Tumor.

     (l) Pulmonary conditions, including, but not limited to:

          (1) Asthma that impedes the ability to perform the activities of daily living and requires daily medication to maintain respiratory function.

          (2) Broncho-pulmonary dysplasia.

          (3) Congenital emphysema.

          (4) Lung hypoplasia associated with diaphragmatic hernia.

          (5) Respiratory distress syndrome. Coverage under the program is limited to 1 day of acute care for the administration of a pulmonary surfactant treatment to reduce long-term deficits.

     (m) Reconstruction, including, but not limited to:

          (1) Burn care and reconstruction. Coverage under the program extends to the date of the initial injury.

          (2) Hemangioma.

          (3) A disfiguring deformity which impedes normal, daily function relative to social or emotional development.

     (Added to NAC by Bd. of Health, eff. 11-27-89; A 1-18-94; R212-97, 7-23-98; R095-99, 11-29-99)