Forum: Air Force Life

EPSDT Special Provision: Exception to Policy Limitations for Recipients under 21 Years of Age
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a federal Medicaid requirement that requires the state Medicaid agency to cover services, products, or procedures for Medicaid recipients under 21 years of age if the service is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition [health problem] identified through a screening examination** (includes any evaluation by a physician or other licensed clinician). This means EPSDT covers most of the medical or remedial care a child needs to improve or maintain his/her health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems. Medically necessary services will be provided in the most economic mode, as long as the treatment made available is similarly efficacious to the service requested by the recipient’s physician, therapist, or other licensed practitioner; the determination process does not delay the delivery of the needed service; and the determination does not limit the recipient’s right to a free choice of providers.
EPSDT does not require the state Medicaid agency to provide any service, product, or procedure
a. that is unsafe, ineffective, or experimental/investigational.
b. that is not medical in nature or not generally recognized as an accepted method of medical practice or treatment.
Service limitations on scope, amount, duration, frequency, location of service, and/or other specific criteria described in clinical coverage policies may be exceeded or may not apply as long as the provider’s documentation shows that the requested service is medically necessary “to correct or ameliorate a defect, physical or mental illness, or a condition” [health problem]; that is, provider documentation shows how the service, product, or procedure will correct or improve or maintain the recipient’s health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.
**EPSDT and Prior Approval Requirements
a. If the service, product, or procedure requires prior approval, the fact that the recipient is under 21 years of age does NOT eliminate the requirement for prior approval.
b. IMPORTANT ADDITIONAL INFORMATION about EPSDT and prior approval is found in the Basic Medicaid Billing Guide, sections 2 and 6, and on the EPSDT provider page. The Web addresses are specified below.
Basic Medicaid Billing Guide: http://www.ncdhhs.gov/dma/medbillcaguide.htm
EPSDT provider page: http://www.ncdhhs.gov/dma/EPSDTprovider.htm
Division of Medical Assistance Clinical Coverage Policy No. 11A-2
High-dose chemotherapy + Total Body Original Effective Date: July 1, 1987
Irradiation IncludingAutologous and Allogeneic Stem Revised Date: May 1, 2007
Cell Support in Acute Myelogenous Leukemia
04242007 3
3.0 When the Procedure Is Covered
IMPORTANT NOTE: EPSDT allows a recipient less than 21 years of age to receive services in excess of the limitations or restrictions below and without meeting the specific criteria in this section when such services are medically necessary health care services to correct or ameliorate a defect, physical or mental illness, or a condition [health problem]; that is, documentation shows how the service, product, or procedure will correct or improve or maintain the recipient’s health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.
EPSDT DOES NOT ELIMINATE THE REQUIREMENT FOR PRIOR APPROVAL IF PRIOR APPROVAL IS REQUIRED. For additional information about EPSDT and prior approval requirements, see Section 2.0 of this policy.
Each recipient’s condition is evaluated on an individual basis. There may be other conditions that are indications for coverage. The N.C. Medicaid program covers high-dose chemotherapy with autologous or allogeneic stem cell support in acute myelogenous leukemia for recipients for recipients who meet indications for transplantation related to the following disease processes:
a. first complete remission for patients with high risk factors such as but not limited to:
1. presence of circulating blasts at the time of diagnosis
2. AML secondary to prior chemotherapy, or radiotherapy for another malignancy
3. difficulty in obtaining a first complete remission
4. certain cytogenetic abnormalities such as: abnormalities of chromosome 12, trisomy of chromosome 8, and deletion of chromosome 5 and 7
5. Monocytoid classification (M4 or M5)
b. treatment of primary refractory AML (does not achieve remission after conventionally dosed chemotherapy)
c. relapsed AML
4.0 When the Procedure Is Not Covered
IMPORTANT NOTE: EPSDT allows a recipient less than 21 years of age to receive services in excess of the limitations or restrictions below and without meeting the specific criteria in this section when such services are medically necessary health care services to correct or ameliorate a defect, physical or mental illness, or a condition [health problem]; that is, documentation shows how the service, product, or procedure will correct or improve or maintain the recipient’s health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.
EPSDT DOES NOT ELIMINATE THE REQUIREMENT FOR PRIOR APPROVAL IF PRIOR APPROVAL IS REQUIRED. For additional information about EPSDT and prior approval requirements, see Section 2.0 of this policy.
The N.C. Medicaid program does not cover high-dose chemotherapy with autologous or allogeneic stem cell support in acute mylegenous leukemia when one of the following conditions exists (not all inclusive):
Division of Medical Assistance Clinical Coverage Policy No. 11A-2
High-dose chemotherapy + Total Body Original Effective Date: July 1, 1987
Irradiation IncludingAutologous and Allogeneic Stem Revised Date: May 1, 2007
Cell Support in Acute Myelogenous Leukemia
04242007 4
a. High-dose chemotherapy and allogeneic stem cell support for relapsing AML after prior therapy with high-dose chemotherapy and autologous stem cell support.
b. Tandem high-dose chemotherapy with autologous stem cell support.
c. History of or active substance abuse - must have documentation of substance abuse program completion plus six months of negative sequential random drug screens.
Note: To satisfy the requirement for sequential testing as designated in this policy, the Division of Medical Assistance (DMA) must receive a series of test (alcohol and drug) results spanning a minimum six-month period, allowing no fewer than a three-week interval and no more than six-week interval between each test during the given time period. A complete clinical packet for prior approval must include at least one documented test performed within one month of the date of request to be considered.
d. Psychosocial history that would limit the ability to comply with medical care pre and post transplant.
e. Current patient and/or caretaker non-compliance that would make compliance with a disciplined medical regime improbable.
Each recipient’s condition is evaluated on an individual basis. There may be other conditions that are indications for non-coverage.