1)
QualChoice
covers reconstructive surgery and related medical, dental, and vision care with
preauthorization for a person of any age who is diagnosed as having a
craniofacial anomaly if the reconstructive surgery and treatment are medically
necessary to improve a functional impairment that results from the craniofacial
anomaly as determined by a nationally approved cleft-craniofacial team, approved
by the American Cleft Palate-Craniofacial Association (ACPA approved team).
2)
Reconstructive surgery and related medical, dental, and vision care for
craniofacial anomaly, including one hearing aid if required, must be provided
by:
a)
A network
participating ACPA approved team; OR
b)
A licensed
and qualified network participating specialist who:
i)
Has received
a diagnosis or evaluation that the patient has a craniofacial anomaly by an ACPA
approved team, either inside the state or outside the state; AND
ii)
Has received
a written authorization or approval of the proposed services and treatment plan
by an ACPA approved team, including approval of any additional services or care
subsequent to the treatment plan; AND
iii)
Agrees it
must maintain clinical records and provide appropriate documentation whenever
requested by an ACPA approved team; AND
iv)
Is willing to
allow the member(s) of the ACPA approved team to closely oversee all treatments;
AND
v)
Also agrees
to the ACPA team providing ongoing review for all authorized services including
accepting any limitations or withdrawal of such approvals depending on the
outcome and medical needs and care of the patient.