1.0 POLICY
1.1 Any physiological
disorder or condition or anatomical loss affecting one or more body
systems which has lasted, or with reasonable certainty is expected
to last, for a minimum period of 12 contiguous months, and which
precludes the person with the disorder, condition or anatomical
loss from unaided performance of at least one of the following major
life activities is an Extended Health Care Option (ECHO) qualifying
condition: breathing, cognition, hearing, seeing, and age appropriate ability
essential to bathing, dressing, eating, grooming, speaking, stair
use, toilet use, transferring, and walking.
1.2 For a beneficiary
less than three years of age, a developmental delay qualifies as
a serious physical disability when the score on the standardized
diagnostic psychometric tests of motor function is two standard
deviations below the mean.
1.3 Serious physical disabilities
include, but are not limited to the following conditions (International
Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM) codes cited for services provided before the mandated
date, as directed by Health and Human Services (HHS), for International
Classification of Diseases, 10th Revision (ICD-10) implementation
or ICD-10-CM codes cited for services provided on or after the mandated
date, as directed by HHS, for ICD-10 implementation) for the purpose
of establishing an ECHO qualifying condition:
1.3.1 Infantile Cerebral Palsy:
ICD-9-CM 343.0 - 343.9 / ICD-10-CM G80.0 - G80.9.
1.3.2 Spina Bifida:
ICD-9-CM 741.0 - 741.93 / ICD-10-CM Q05.0 - Q05.9.
1.3.3 Vision:
ICD-9-CM 369.01 - 369.08 inclusive; 369.11 - 369.14 inclusive; 369.21;
369.22; 369.4 / ICD-10-CM H54.0 - H54.12 inclusive; H54.8.
1.3.4 Hearing-Testable
Patients: as determined by audiologic function tests:
• A pure tone hearing
threshold level of 45 decibels or greater in one ear; or by
• A pure tone hearing
threshold level of 30 decibels or greater in both ears; or by
• Speech discrimination
of 60% or poorer with either ear.
1.3.5 Hearing-Non-Testable
Patients: Where pure tone audiometry or speech discrimination testing
is not available or reliable, the attending physician must submit
documentation which demonstrates the patient is unable to engage
in basic productive activities of daily living expected of unimpaired
persons of the same age group.
1.3.6 Breathing: Total reliance
upon a respirator.
1.3.7 Acquired or congenital total
loss, or loss of use, of an arm or leg.
1.3.8 Autism Spectrum Disorder (ASD):
ICD-10-CM F84.0, (Autistic Disorder).
1.3.9 Multiple Sclerosis (MS): ICD-9-CM
340.