SECTION 317:30-5-210.2. Coverage for children

(a)   Coverage. Coverage of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) for children includes the specified coverage for adults found in OAC 317:30-5-211.1 through OAC 317:30-5-211.18. In addition the following are covered items for children only:

(1)   Orthotics and prosthetics.

(2)   Enteral nutrition is considered medically necessary for certain conditions in which, without the products, the member's condition would deteriorate to the point of severe malnutrition.

(A)   Enteral nutrition must be prior authorized. PA requests must include:

(i)   the member's diagnosis;

(ii)   the impairment that prevents adequate nutrition by conventional means;

(iii)   the member's weight history before initiating enteral nutrition that demonstrates oral intake without enteral nutrition is inadequate;

(iv)   the percentage of the member's average daily nutrition taken by mouth and by tube; and

(v)   prescribed daily caloric intake.

(B)   Enteral nutrition products that are administered orally and related supplies are not covered.

(3)   Continuous positive airway pressure devices (CPAP).

(b)   EPSDT. Services deemed medically necessary and allowable under federal regulations may be covered by the EPSDT Child Health program even though those services may not be part of the SoonerCare program. These services must be prior authorized.

(c)   Medical necessity. Federal regulations require OHCA to make the determination as to whether the service is medically necessary and do not require the provision of any items or services that the State determines are not safe and effective or that are considered experimental.

[Source: Added at 27 Ok Reg 453, eff 12-3-09 (emergency); Added at 27 Ok Reg 942, eff 5-13-10; Amended at 32 Ok Reg 728, eff 7-1-15 (emergency); Amended at 33 Ok Reg 857, eff 9-1-16]