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TRICARE Policy Manual 6010.60-M, April 1, 2015
Extended Care Health Option (ECHO)
Chapter 9
Section 2.3
Eligibility - Qualifying Condition: Serious Physical Disability
Issue Date:  July 3, 1997
Authority:  32 CFR 199.5(b)(2)(ii), 10 USC 1079(d)(3)
Revision:  
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.
2.0  EFFECTIVE DATE
September 1, 2005.
- END -

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