Medical Policy
Effective Date:01/01/2016 Title:Craniofacial Anomaly Reconstructive Surgery
Revision Date: Document:BI498:00
CPT Code(s):None
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

All reconstructive surgery and medical, dental, or vision care for craniofacial anomalies, including but not limited to cleft lip and cleft palate, requires preauthorization.  This care includes provision of one hearing aid if required.

QualChoice covers reconstructive surgery for craniofacial anomalies consistent with state law.
Medical Statement

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.
Limits
Intentially left empty
Reference

1)    Arkansas Insurance Department Rule 111

2)    Ark. Code Ann. 23-79-1501, et seq.
Application to Products
This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.