Categories of Care

PURPOSE: This rule defines the medical conditions for which MCCS will provide service and funding. (1) Category I shall include those eligible applicants whose medical conditions require immediate life-saving medical treatment. The conditions include, but are not necessarily limited to: (A) Burn care—any burns requiring seven (7) days or more inpatient care and burns requiring skin grafting; (B) Cardiac care—congenital heart disease requiring surgical intervention or presenting with congestive heart failure; and acute rheumatic fever with congestive heart failure or requiring cardiac surgery; (C) Cleft lip and palate care—initial lip or palate closure or both; (D) Genito-urinary (GU) care—bladder extrophy, vesico-ureteral reflux and ureteropelvic junction obstruction; (E) Myelomeningocele care (spina bifida)—surgical closure of myelocele; (F) Neurology care—depressed skull fracture, subdural hematoma and uncontrolled seizures; (G) Neurosurgery care—shunting procedures; (H) Orthopedic care—acquired amputations, fractures and fracture dislocations of the vertebral column with or without associated spinal cord injury except for closed coccygeal fractures, open fractures, osteogenesis imperfecta, osteomyelitis or pyarthrosis presenting with sepsis; and (I) Pediatric surgery care—diaphragmatic hernia with accompanying respiratory distress; Hirschsprung’s disease; multiple surgically-staged imperforate anus; duodenal atresia; jejunal atresia; tracheoesophageal fistula; gastroschisis; omphalocele; intestinal obstruction in neonates; lacerated tendons; electrical burns to the mouth; surgical procedures for subglottic stenosis; laryngeal webs; choanal atresia; and ingestion burns; and (J) The following are not covered under Category I: arthritis care; cerebral palsy care; ear; nose and throat (ENT)/hearing care; ENT/surgical care; and physical, medical and rehabilitation (PM&R) care. (2) Category II shall include those medical conditions which, if not treated, could grow worse or cause a crippling disability. A limited term of hospitalization and a good prognosis should be expected. The conditions may include, but are not necessarily limited to: (A) Arthritis care—acute juvenile rheumatoid arthritis; (B) Burn care—follow-up and rehabilitation services; (C) Cardiac care—congenital heart disease (CHD) not requiring immediate surgical intervention and CHD not presenting with congestive heart failure; (D) Cerebral palsy care—surgical procedures and bracing; (E) Cleft lip and palate care—surgical procedures; (F) Ear, nose and throat (ENT) surgical care—surgical procedures for chronic otitis media, tympanic membrane perforation, cholesteatoma and other otologic conditions requiring specialty care; (G) Genito-urinary care—bladder exstrophy, vesicoureteral reflux, utreteropelvic junction obstruction, hypospadias and ambiguous genitalia; (H) Myelomeningocele care (spinal bifida)—follow-up and rehabilitation services: (I) Neurology care—residuals of meningitis, Guillain-Barre syndrome, Reye’s syndrome, poliomyelitis, seizure disorders and stalic encephalopathies; (J) Neurosurgery care—hydrocephanlus, diastematomyelia, enecephalocele and vascular lesions affecting the central nervous system; (K) Orthopedic care—congenital deformities; arthrogryposis congenital dysplasia of the hip; complicated fractures of the limbs, pelvis and shoulder girdle; scoliosis and kyphosis; surgical treatment of late effects of epiphyseal injury; osteomyelitis; closed spinal fracture without neurologic deficit, excluding coccygeal fractures; rickets; LeggCalve-Perthes disease; club feet; nonmalignant bone tumors and acquired injury to limbs; (L) Pediatric surgery care—benign tumors, hemangiomas, lymphangiomas and neurofibromas which cause functional impairment or disfigurement and surgical correction of laryngeal papillomas; (M) Physical, medical and rehabilitation (PM&R) care—rehabilitation for spinal cord injuries; and (N) The following are not covered under Category II: ear, nose and throat (ENT)/hearing care. (3) Category III shall include those eligible applicants whose conditions may require prolonged outpatient care and may require hospitalization at some time. The conditions have a fair prognosis if treated and may include, but are not necessarily limited to: (A) Arthritis care—juvenile sheumatoid arthritis follow-up as needed; (B) Burn care—covered under Category I and II; (C) Cardiac care—congenital heart disease follow-up and resistant dysrhythmias; (D) Cerebral palsy care—rehabilitation services; (E) Cleft lip and palate care—surgical revisions, dental care and speech therapy; (F) Ear, nose and throat (ENT)/hearing care—all eligible services; (G) Ear, nose and throat (ENT)/surgical care—surgical care follow-up; (H) Genito-urinary care—follow-up care as needed; (I) Myelomeningocele care—covered under Categories I and II; (J) Neurology care—residuals of meningitis, seizure disorders, Guillain-Barre syndrome, Reye’s syndrome, poliomyelitis and stalic encephalopathies; (K) Neurosurgery care—hydrocephalus, diastematomyelia, encephalocele and vascular lesions affecting the central nervous system; (L) Orthopedic care—claw foot, calcaneovalgus and other acquired congenital deformities and rehabilitation services; (M) Pediatric surgery care—follow-up care as needed; and (N) Physical, medical and rehabilitation (PM&R) care—covered under Category II. (4) Category IV shall include those eligible applicants whose medical conditions have a poor to fair prognosis or uncertain restoration to a useful or productive life regardless of the treatment provided. The conditions are considered to be maintained by the services that are provided for them and thus are put in this category of maintenance. This is primarily a category of case management and covers the entire spectrum of CCS-eligible conditions. (5) Category V shall include all those eligible applicants whose medical conditions have variable prognosis; enhancement allows improvements in activities of daily living (ADL), physical appearance for psychological reasons, with plastic surgical procedures, etc. This also includes exotic conditions such as craniofacial anomalies which are not ordinarily eligible for CCS services due to budgetary limitations; if funding allows, these conditions would be included under this category. Cosmesis, inborn errors of metabolism, exotic drugs and special counseling are some of the miscellaneous items that would be funded in this category. (6) The categories in sections (1)–(5) of this rule may have funding ceilings or limitations imposed on them or may be categorically suspended, as stipulated in 19 CSR 401.060(1)(B). AUTHORITY: sections 192.005.2 and 201.060, RSMo 1986.* This rule was previously filed 13 CSR 50-160.030. Emergency rule filed Dec. 12, 1984, effective Dec. 22, 1984, expired April 20, 1985. Original rule filed Dec. 12, 1984, effective April 11, 1985. Emergency amendment filed Feb. 20, 1985, effective March 2, 1985, expired June 30, 1985. Emergency amendment filed April 11, 1985, effective April 21, 1985, expired June 30, 1985. Amended: Filed June 2, 1987, effective Aug. 13, 1987. *Original authority: 192.005, RSMo 1985 and 201.060, RSMo 1959.