CHILDREN'S SPECIAL HEALTH SERVICES



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SPECIAL HEALTH SERVICES MEDICAL CONDITIONS Revised: 5-22-2019

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ACQUIRED BRAIN INJURY (S06.9)

ACUTE FLACCID MYELITIS (G04.91

ADENOID HYPERTROPHY causing SLEEP APNEA (J35.2)

ALPHA 1-ANTITRYPSIN DEFICIENCY (E88.01)

AMPUTATION (S88.91)

AMYOTONIA CONGENITA requiring rehabilitative measures (G71.12)

ANAL STENOSIS & IMPERFORATE ANUS (Q42.9)

ANEMIAS (excluding minor anemias), including sickle cell (D58.9)

APLASIA CUTIS CONGENITA, severe, requiring surgery & ECTODERMAL DYSPLASIA (Q82.4)

ARNOLD-CHIARI DEFORMITY (Q07.0)

ARTHROGRYPOSIS (Q74.3)

ASTHMA, persistent, requiring controller medications (J45.9)

ATAXIAS, FAMILIAL DEGENERATIVE DISEASE requiring rehabilitative measures (G11.9)

ATTENTION DEFICIT/HYPERACTIVITY DISORDER (ADD/ADHD) (F90)

AUTO-IMMUNE DISORDERS, chronic, severe, and complex in nature (M35.9)

BILE DUCT ATRESIA (Q44.2)

BIRTH INJURY (ERB's PALSY, etc.) requiring bracing or surgery (P14.0)

BONE CYST requiring surgery (M85.60)

BONE TUMORS, benign, requiring surgery, including OSTEOCHONDROMAS D16.9)

BONY DEFORMITIES requiring bracing, casting or surgery & POST-TRAUMATIC DEFORMITY (orthopedic or severe soft tissue deformity due to injury; excluding acute fracture without an underlying condition) (M95.9)

BRAIN TUMORS requiring surgery and/or radiation (D49.6)

BRANCHIOGENIC CLEFT CYST requiring surgery (Q18.2)

BREAST HYPOPLASIA causing considerable psychological problems requiring surgery (N64.82)

BURNS, severe, acute, including residuals (T30.3)

CANCER, including CANCER OF EYE (C80.1)

CATARACTS (Q12.0)

CELIAC DISEASE (K90.0)

CEREBRAL PALSY, congenital or acquired, requiring

rehabilitative measures (G80.9)

CHOANAL ATRESIA (Q30.0)

CHRONIC LUNG/LOWER AIRWAY CONDITIONS, including chronic lung disease, chemical pneumonitis, and subglottic stenosis (J98.4)

CLEFT LIP AND/OR PALATE, including SHORT PALATE and SUBMUCOUS CLEFT (Q35.9)

COLLAGEN VASCULAR DISORDERS, including but not limited to lupus, dermatomyositis, scleroderma, Sjogren’s syndrome, and rheumatoid arthritis (M35.9)

CONGENITAL ADRENAL HYPERPLASIA (CAH) (E25.0)

CORNEAL TRANSPLANTS (Z94.7)

CRANIOSTENOSIS (premature synostosis) (Q75.0)

CYSTIC FIBROSIS (E84.9)

CYSTIC HYGROMA (D18.1)

CYSTINOSIS (E72.04)

DENTAL DISORDERS, congenital (K00.5)

DERMATOMYOSITIS (M36.0)

DIABETES INSIPIDUS (E23.2)

DIABETES MELLITUS, TYPE I and TYPE II (E10 & E11)

DIAPHRAGMATIC HERNIA (K44.9)

DISLOCATION OF HIPS OR OTHER JOINTS (S73.006)

DOWN SYNDROME (Q90)

EAR DEFORMITY (Q17.9)

EHLERS-DANLOS DISEASE (Q79.6)

ENCEPHALITIS, POLIOMYELITIS OR MENINGITIS,

residuals of (B94.1)

ENUCLEATION (removal of eyeball) (S05.70)

EOSINOPHILIC GASTROENTERITIS (K52.81)

EPIDERMOLYSIS BULLOSA (Q81.9)

ESOPHAGEAL VARICES (I85.0)

EYE WOUNDS, penetrating (S05.40)

EYELID DEFORMITY requiring surgery, congenital (Q10.3)

FACE DEFORMITY (Q18.9)

FEMORAL CAPITAL EPIPHYSIS, slipped (M93.0)

GASTROINTESTINAL TRACT ANOMALIES, congenital

(including gastroschisis) (Q45.9)

GENITO-URINARY TRACT ANOMALIES, congenital, severe and requiring surgery (Q64.9)

GENU RECURVATUM, severe (Q64.8)

GENU VALGUM (Knock-knees), severe (Q74.1)

GENU VARUM (Bowed legs), severe (Q74.1)

GLAUCOMA, congenital (Q15.0))

GROWTH HORMONE DEFICIENCY (E23.0)

GUILLAIN-BARRE DISEASE, severe, acute, requiring tracheotomy and/or ventilation, including residuals (G61.0)

HEARING LOSS (H91.90)

HEART CONDITIONS, congenital or acquired (Q24.9)

HEMANGIOMA, medically significant (D18.00)

HEMOGLOBINOPATHIES, limited to:

Sickle cell anemia (D57.1)

Thalassemia (D56.9)

HEMOPHILIA including deformities (D66)

HISTIOCYTOSIS X (eosinophilic granuloma) C96.6)

HYDROCEPHALUS requiring surgery (G91.9)

HYPERCHOLESTEROLEMIA, congenital, including familial combined hyperlipidemia (E78.0)

HYPERTHYROIDISM (E05.9)

HYPOPARATHYROIDISM, congenital or if suspected to last longer than two years (E20.9)

HYPOPHOSPHATEMIC RICKETS (E83.31)

HYPOPITUITARISM (E23.0)

HYPOTHALAMIC ADRENAL INSUFFICIENCY (E23.3)

HYPOTHYROIDISM (E03.9)

ICHTHYOSIFORM ERYTHRODERMA, congenital, severe (Q80.3)

IMMUNODEFICIENCY STATES including severe combined

immunodeficiency (SCID) (D81.9)

INFLAMMATORY BOWEL DISEASE including Crohn’s

Disease and ulcerative colitis (K50.9)

INTERSEX DISORDERS, congenital (Q56)

JOINT DEFORMITY, CLUBFEET AND CLUBHANDS, severe, requiring bracing, casting, surgery or physical therapy (Q74.9)

JUVENILE IDIOPATHIC ARTHRITIS, (Juvenile

Rheumatoid Arthritis) (M08.00)

KYPHOSIS, adolescent, requiring bracing or surgery (M40.209)

LARYNGEAL PAPILLOMA (D14.1)

LEUKEMIA (C95.9)

LEUKODYSTROPHY, including adrenoleukodystrophy (E75.25)

MALOCCLUSION, handicapping (M26.4)

MASTOIDITIS, chronic (H70.10)

MEGACOLON requiring surgery (Q43.1)

METABOLIC DISORDERS/INBORN ERRORS OF

METABOLISM

Amino Acid Disorders, limited to:

Arginase deficiency/Hyperargininaemia (E72.20)

Argininemia (E72.21)

Argininosuccinic acidemia (ASA lyase deficiency)

(E72.22)

Carbamoyl phosphate synthetase deficiency (E72.29)

Citrullinemia (ASA synthetase deficiency) (E72.23)

Glutaric acidemia/aciduria (E72.3)

Glutathione synthetase deficiency (5-oxoprolinuria)

(D55.1)

Homocystinuria (cystathione synthase deficiency)

(E72.11)

Hypermethioninemia (E72.10)

Hyperornithinemia, hyperammonemia, (E72.4)

Homocitrullinemia (HHH syndrome) (E72.4)

Hyperornithinemia or ornithine oxo-acid

aminotransferase deficiency (E72.4)

Maple syrup urine disease (MSUD) (E71.0)

N-Acetylglutamate synthetase deficiency (E74.09)

Nonketotic hyperglycinemia (E72.51)

Ornithine aminotransferase deficiency (E72.4)

Ornithine transcarbamylase deficiency (OTC) (E72.4)

Phenylketonuria (PKU), includes phenylalanine

hydroxylase deficiency (PAH) and

hyperphenylalaninemia (E70.0)

Tyrosinemia (I, II, III); (E70.21)

Biotinidase Deficiency (E81.810)

Fatty Acid Oxidation Disorders, limited to:

2,4 dienoyl-CoA reductase deficiency (E71.31

Long chain acyl-CoA dehydrogenase deficiency

(LCADD) (E71.31)

Long chain 3-OH acyl-CoA dehydrogenase deficiency

(LCHAD) (E71.31)

Carnitine/acylcarnitine translocase deficiency (CACT)

(E71.40)

Carnitine palmitoyltransferase deficiency-type I

(CPTI) (E71.40)

Carnitine palmitoyltransferase deficiency-type II

(CPTII) (E71.40)

Carnitine transport defect (CTD) (E71.40)

Glutaric acidemia/aciduria (E72.3)

Medium chain acyl-CoA dehydrogenase deficiency

(MCAD) (E71.311)

Multiple acyl-CoA dehydrogenase deficiency

(MADD) or glutaric acidemia-type II (GAII)

(E71.313)

Short chain acyl-CoA dehydrogenase deficiency

(SCAD) (ethylmalonic academia) (E71.312)

Trifunctional protein deficiency (TFP Deficiency)

(E71.31)

Very long chain acyl-CoA dehydrogenase deficiency

(VLCAD) (E71.310)

Galactosemia (E74.21)

GLUT 1 Deficiency (glucose 1 transporter deficiency) (E74.9)

Glycogen Storage Disease (E74.00)

Hereditary Fructose Intolerance (E74.12)

Organic Acid Disorders, limited to:

2-methylbuyryl-CoA dehydrogenase deficiency

(E71.118)

3-methylcrotonyl-CoA carboxylase deficiency (E71.111)

3-methylglutaconic-CoA hydratase deficiency (E71.111)

3-hydroxy-3-methylglutaryl-CoA lyase deficiency

(E71.111)

Glutaric acidemia/aciduria (E72.3)

Isobutyryl-CoA dehydrogenase deficiency (E71.118)

Isovaleric acidemia (IVA) (E71.110)

Methylmalonic acidemia (MMA) (E71.120)

Propionic Acidemia (E71.121)

Mitochondrial acetoacetyl-CoA thiolase deficiency

(BKT, 3-ketothiolase deficiency) (E71.118)

Multiple CoA carboxylase deficiency (E72.9)

Refsum’s Disease (Phytanic acid restriction) (G60.1)

MICROCEPHALY (Q02)

MUCOPOLYSACCHARIDOSIS (MPS) (including variants)

(E76.3)

NARCOLEPSY (with or without Cataplexy) (G47.41)

NEPHROSIS & CHRONIC NEPHRITIS (N03.9)

NERVE INJURIES, chronic (S14.9)

NEUROFIBROMATOSIS (Q85.00)

NEUROMUSCULAR DISORDERS limited to those covered

by MDA including muscular dystrophy (G70.9)

NEVI with malignant potential (D22.9)

OCULAR ALBINISM, congenital (E70.319)

OSTEOCHONDRITIS of various bones (M92.9)

OSTEOGENESIS IMPERFECTA (Q78.0)

OSTEOMYELITIS, residuals of (M86.9)

PANTOTHENATE KINASE-ASSOCIATED

NEURODEGENERATION (PKAN)

(Hallervorden-Spatz Disease, including infusion pump)

(G23.0)

PARAPLEGIA, traumatic, and its direct complications (G82.20)

PECTUS CARINATUM/PECTUS EXCAVATUM requiring surgery (Q67.7)

PERTHES DISEASE (M91.10)

POLYCYSTIC KIDNEY DISEASE (Q61.3)

PRECOCIOUS PUBERTY (E30.1)

PSEUDOHYPOPARATHYROIDISM (E20.1)

PSORIASIS (L40.54)

PTOSIS (drooping eyelids) (H02.409)

PULMONARY LOBAR EMPHYSEMA (J43.9)

RETINAL DETACHMENT in Marfan's syndrome (Q87.42)

RETROLENTAL FIBROPLASIA (retinopathy of prematurity)

(H35.179)

SCLERODERMA (M34.9)

SCOLIOSIS requiring bracing or surgery (M41.9)

SEIZURE DISORDERS, excluding febrile seizures (R56.9)

SHORT BOWEL SYNDROME (K91.2)

SPINA BIFIDA, MENINGOCELE, MYELOCELE (Q05.9)

STRABISMUS through age 10 (H50.9)

SUBLUXATED EYE LENS in Marfan's syndrome (H27.119)

SUPERNUMERARY PARTS, severe (Q89.9)

SYNDACTYLY (Q70.9)

SYNDROMES, limited, requiring ongoing medical treatment; includes septo-optic dysplasia (Q89.7)

THROMBOCYTOPENIA, congenital (D69.42)

THROMBOEMBOLISM (E82.4)

THYROGLOSSAL DUCT CYST (Q89.2)

T-LYMPHOCYTE IMMUNE DEFICIENCY STATE (D83.1)

TORTICOLLIS (not spasmodic, requiring casting or surgery)

(M43.6)

TRACHEAL STENOSIS (J95.03)

TRACHEOESOPHAGEAL FISTULA (Q39.2)

TRANSVERSE MYELITIS (G37.3)

TUBERCULOSIS OF BONES AND JOINTS (A18.0)

TUBEROUS SCLEROSIS (Q85.1)

UNDESCENDED TESTES (Q53.9)

VASCULAR ABNORMALITIES (Q25, Q26, Q27, Q28)

WEGENER’S GRANULOMATOSIS (M31.3)

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