Overview of CCS Medical Eligibility
This brief summary document has been developed solely for the convenience and use in understanding the general medical eligibility criteria of the CCS program. It is not an authoritative statement of, and may not be cited as authority, for any decisions, determinations, or interpretations under the CCS program.
Please refer to the California Code of Regulations, Title 22, Division 2, Subdivision 7, Chapter 3, Article 2, Sections 41515.1-41518.9 for full description. The applicable medical eligibility section is noted with each category below.
Section 41515.2: Infectious Diseases (ICD-10 A00-B99)
CCS applicants diagnosed with at least one of the following shall be medically eligible for participation in the CCS program:
(a) Infections of the bone, such as osteomyelitis and periostitis.
(b) Infections of the eye when the infection, if untreated, may result in permanent visual impairment or blindness.
(c) Infections of the central nervous system which have produced a neurologic impairment that results in physical disability requiring surgery or rehabilitation services to regain or improve function, such as movement or speech, which was limited or lost as a result of the infection.
(d) Infections acquired in utero and for which medically necessary postnatal treatment is required, such as toxoplasmosis, cytomegalovirus infection, rubella, herpes simplex, and syphilis.
(e) Human Immunodeficiency Virus (HIV infection), when confirmed by laboratory tests.
Section 41516: Neoplasms (ICD-10 C00-D49)
CCS applicants with at least one of the following conditions shall be medically eligible for participation in the CCS program:
(a) All malignant neoplasms, including leukemia.
(b) A benign neoplasm when either of the following is present:
(1) The neoplasm is physically disabling or severely disfiguring; or
(2) The neoplasm is located contiguous to or within a vital organ or body part, and its continued growth or lack of treatment would limit or eliminate the function of the organ or body part or lead to the death of the applicant.
Section 41516.1: Endocrine, Nutritional, and Metabolic Diseases, and Immune Disorders (ICD-10 E00-E89)
CCS applicants with at least one of the following conditions shall be medically eligible for participation in the CCS program:
(a) Diseases of the pituitary, thyroid, parathyroid, thymus, and adrenal glands.
(b) Growth hormone deficiency.
(c) Diseases of the ovaries or testicles in which there is delayed onset of puberty primary amenorrhea after the age of 15 years, sexual development prior to the age of eight years for females and nine years for males, feminization of a male, or virilization of a female.
(d) Diseases of the pancreas resulting in pancreatic dysfunction.
(f) Diseases due to congenital or acquired immunologic deficiency manifested by life-threatening infections, as determined from medical information about the applicant's clinical course and laboratory studies.
(g) Inborn errors of metabolism such as phenylketonuria, homocystinuria, galactosemia, glycogen storage disease and maple syrup urine disease.
(h) Cystic fibrosis.
Section 41516.3: Diseases of Blood and Blood-Forming Organs (ICD-10 D50-D89)
CCS applicants with at least one of the following conditions shall be medically eligible for participation in the CCS program:
(a) Anemias due to abnormal production of red cells or hemoglobin;
(b) Anemias resulting solely from a nutritional deficiency, such as inadequate intake of iron, folic acid or Vitamin B12 are eligible only when they present with life-threatening complications;
(c) Hemolytic anemias such as, but not limited to, congenital spherocytosis, sickle cell disease, the thalassemias and erythroblastosis fetalis;
(d) Hemolytic anemias resulting from infection are eligible only when they present with life-threatening complications;
(e) Pancytopenias, such as the congenital and acquired aplastic anemias;
(f) Disorders of leukocytes such as acquired and congenital neutropenia and chronic granulomatous disease;
(g) Hemorrhagic diseases due to:
(1) Coagulation disorders such as the hemophilias and von Willebrand disease; or
(2) Disorders of platelets that are life threatening;
(h) Other disorders of blood and blood-forming organs that are life-threatening such as polycythemia, hypersplenism and hypercoagulable states.
Section 41517: Mental Disorders and Mental Retardation (ICD-10 F01-F99)
(a) CCS applicants with a mental disorder, whose application is based upon such a disorder, shall not be medically eligible for the CCS program.
(b) CCS applicants with mental retardation, whose application is based upon such disease, shall not be medically eligible for the CCS program.
Section 41517.3: Diseases of the Nervous System (ICD-10 G00-G99)
(a) CCS applicants with at least one of the following conditions shall be medically eligible for participation in the CCS program:
(1) Noninfectious diseases of the central and peripheral nervous system which produce a neurologic impairment that is life threatening or physically disabling.
(2) Cerebral palsy, a motor disorder with onset in early childhood resulting from a non-progressive lesion in the brain manifested by the presence of one or more of the following:
(A) Rigidity or spasticity.
(B) Hypotonia, with normal or increased deep tendon reflexes, and exaggeration of or persistence of primitive reflexes beyond the normal age range.
(C) Involuntary movements that are described as athetoid, choreoid, or dystonic.
(D) Ataxia manifested by incoordination of voluntary movement, dysdiadochokinesia, intention tremor, reeling or shaking of trunk and head, staggering or stumbling, and broad-based gait.
(3) Seizure disorder when either of the following occur:
(A) It is a component of or secondary to a CCS-eligible condition; or
(B) It is of unknown origin and one of the following exists:
1. The frequency or duration of the seizures requires more than four changes in dosage or type of medications in the 12 months preceding the initial or subsequent determination of medical eligibility;
2. The frequency or duration of the seizures requires two or more types of seizure medications each day;
3. The frequency or duration of the seizures requires at least a monthly medical office visit for assessment of the applicant's clinical status and periodic blood tests for medication levels or presence of blood dyscrasia; or
4. The applicant has experienced an episode of Status Epilepticus in which case medical eligibility shall extend for one year following that event.
(4) Congenital anomalies of the nervous system which meet the criteria of section 41518.8.
(b) When the eligibility criteria listed in subsection (a)(3)(B) above have not been present for at least one year, eligibility shall cease.
(a) CCS applicants with at least one of the following conditions shall be medically eligible for participation in the CCS Medical Therapy Program:
(1) Cerebral palsy as specified in Section 41517.3(a)(2).
(2) Neuromuscular conditions that produce muscle weakness and atrophy, such as poliomyelitis, myasthenias, and muscular dystrophies.
(3) Chronic musculoskeletal and connective tissue diseases or deformities such as osteogenesis imperfecta, arthrogryposis, rheumatoid arthritis, amputations, and contractures resulting from burns.
(4) Other conditions manifesting the findings listed in section 41517.3(a) above, such as ataxias, degenerative neurological disease, or other intracranial processes.
(b) CCS applicants under three years of age shall be eligible when two or more of the following neurological findings are present:
(1) Exaggerations of or persistence of primitive reflexes beyond the normal age (corrected for prematurity);
(2) Increased Deep Tendon Reflexes (DTRs) that are 3+ or greater;
(3) Abnormal posturing as characterized by the arms, legs, head, or trunk turned or twisted into an abnormal position;
(4) Hypotonicity, with normal or increased DTRs, in infants below one year of age. (Infants above one year must meet criteria described in (a)(1)); or
(5) Asymmetry of motor findings of trunk or extremities.
Section 41517.7: Diseases of the Eye (ICD-10 H00-H59)
CCS applicants with at least one of the following eye conditions shall be medically eligible for participation in the CCS program:
(a) Strabismus, when surgery is required and either until fusion is obtained, or a visibly abnormal deformity is corrected.
(b) Infections that produce permanent visual impairment or blindness, such as keratitis and choroiditis.
(c) Infections that require ophthalmological surgery, such as chronic dacryocystitis.
(d) Other diseases that can lead to permanent visual impairment such as:
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(4) Optic atrophy or hypoplasia. |
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(7) Retinopathy of prematurity. |
(8) Persistent hyperplastic primary vitreous. |
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(e) Congential anomalies of the eye which meet the criteria of section 41518.8.
Section 41518: Diseases of the Ear and Mastoid (ICD-10 H60-H95)
(a) CCS applicants shall be eligible for participation in the CCS program for diagnostic services to determine the presence of a hearing loss when the applicant:
(1) Fails two pure tone audiometric hearing screening tests performed at least six weeks apart at levels not to exceed 25 decibels and at the minimum number of frequencies of 1000, 2000 and 4000 Hertz; or
(2) Fails to have normal auditory brain stem evoked response; or
(3) Fails otoacoustic emission or behavioral responses to auditory stimuli as determined by two tests performed at least six weeks apart; or
(4) Fails to pass hearing screening provided through the Newborn and Infant Hearing Screening, Tracking and Intervention Program, pursuant to Health and Safety Code Sections 123975 and 124115 through 124120.5; or
(5) Exhibits symptoms that may indicate a hearing loss such as poor speech for age or delay in age-appropriate behavioral milestones; or
(6) Has documentation of one of the risk factors associated with a sensorineural hearing or conductive hearing loss such as:
(A) A family history of congenital or childhood onset of hearing impairment.
(B) Congenital infection known or suspected to be associated with hearing loss.
(C) Craniofacial anomalies.
(D) Hyperbilirubinemia at a level exceeding the indication for an exchange transfusion.
(E) Ototoxic medications used for more than five days.
(F) Bacterial meningitis.
(G) Severe depression at birth, defined as:
1. Apgar score of three or less;
2. Failure to initiate spontaneous respirations by ten minutes of age; or
3. Hypotonia persisting to two hours of age.
(H) Prolonged mechanical ventilation for a duration of at least five days.
(I) Findings of a syndrome known to be associated with hearing loss.
(b) If either of the tests referenced in (a)(1) and (3) above are performed by an audiologist or otolaryngologist, only one exam shall be required for eligibility for diagnostic testing.
(c) CCS applicants shall be eligible for participating in the CCS program for treatment services when there is a hearing loss present as defined by the following criteria:
(1) In children over five years of age, a pure tone audiometric loss of 30 decibels or greater at two or more frequencies in the same ear tested at 500, 1000, 2000, 3000, 4000, 6000, 8000 Hertz or a loss of 40 decibels or greater at any one frequency between and including 500 through 8000 Hertz;
(2) In children from three to five years of age, a pure tone audiometric loss of 30 decibels or greater at any frequency tested at 500, 1000, 2000, 3000, 4000, 6000, 8000 Hertz; or
(3) In children unable to complete a pure tone audiometric test and whose auditory brain stem evoked response, or otoacoustic emission, or behavioral responses to auditory stimuli indicate hearing loss of 30 decibels or greater.
(d) CCS applicants shall be eligible for participation in the CCS program for treatment services when there is:
(1) Perforation of the tympanic membrane that requires tympanoplasty; or
(e) Congenital anomalies of the ear and mastoid process that meet the criteria of section 41518.8.
Section 41518.2: Diseases of the Circulatory System (ICD-10 I00-I99)
CCS applicants with at least one of the following conditions shall be medically eligible for participation in the CCS program:
(a) Diseases of the endocardium, myocardium, or pericardium;
(b) Cardiac dysrhythmias requiring medical or surgical intervention;
(c) Diseases of blood vessels such as embolism, thrombosis, aneurysms, and periarteritis;
(d) Cerebral and subarachnoid hemorrhage;
(e) Chronic diseases of the lymphatic system;
(f) Primary hypertension that requires medication to control; or
(g) Congenital anomalies of the circulatory system that meet the criteria of section 41518.8.
Section 41518.3: Diseases of the Respiratory System (ICD-10 J00-J99)
CCS applicants with at least one of the chronic conditions of the respiratory tract, such as the following conditions, shall be eligible for participation in the CCS program:
(a) Chronic pulmonary infections such as abscess or bronchiectasis;
(c) Chronic Lung Disease (CLD) of infancy, such as Bronchopulmonary Dysplasia (BPD), when either (1) or (2) below is met:
(1) History of care in a neonatal intensive care unit that includes all of the following:
(A) Mechanical ventilation for more than six days;
(B) Concentration of oxygen greater than 60 percent for more than four of the days of ventilation; and
(C) Need for supplemental oxygen for more than 30 days; or
(2) The presence in an infant of at least one of the following:
(A) Radiographic changes characteristic of CLD such as areas of hyperinflation, areas of radiolucency, and areas of radio density due to peribronchial thickening or patchy atelectasis;
(B) Impaired pulmonary function, as manifested by one or more of the following during a stable phase: increased airway resistance, increased residual capacity, decreased dynamic compliance, arterial CO2 tension (PaCO2) greater than 45 or arterial O2 tension (PaO2) less than 80; or
(C) Cardiovascular sequelae such as pulmonary or systemic hypertension or right or left ventricular hypertrophy.
(d) Asthma, when it has produced chronic lung disease;
(e) Chronic disorders of the lung that are the result of chemical injury, metabolic disorders, genetic defects, or immunologic disorders other than asthma;
(f) Respiratory failure requiring ventilatory assistance;
(g) Hyaline membrane disease; or
(h) Congenital anomalies of the respiratory system that meet the criteria of section 41518.8.
Section 41518.4: Diseases of the Digestive System (ICD-10 K00-K95)
CCS applicants with at least one of the following conditions shall be eligible for participation in the CCS program:
(a) Diseases of the liver including:
(2) Chronic liver disease;
(b) Disorders of the gastrointestinal tract including:
(1) Chronic inflammatory diseases requiring complex ongoing medical management or surgical intervention such as pancreatitis, peptic ulcer, ulcerative colitis, regional enteritis, diverticulitis, and cholecystitis;
(2) Chronic intestinal failure; or
(3) Gastroesophageal reflux when:
(A) It is part of or complicates the management of a CCS-eligible condition; or
(B) It is an isolated condition with complications such as esophageal stricture or chronic aspiration pneumonia.
(c) Congenital anomalies of the digestive system that meet the criteria of section 41518.8.
Section 41518.5: Diseases of the Genitourinary System (ICD-10 N00-N99)
CCS applicants with at least one of the following conditions shall be medically eligible for participation in the CCS program:
(a) Acute glomerulonephritis in the presence of acute renal failure, malignant hypertension, or congestive heart failure;
(b) Chronic glomerulonephritis, chronic nephrosis, or chronic nephrotic syndrome;
(c) Chronic renal insufficiency;
(d) Obstructive uropathies;
(e) Vesicoureteral reflux, grade II or greater;
(g) Congenital anomalies of the genitourinary tract that meet the criteria of section 41518.8.
Section 41518.6: Diseases of the Skin and Subcutaneous Tissues (ICD-10 L00-L99)
CCS applicants with at least one of the following conditions shall be medically eligible for participation in the CCS program:
(a) Persistent or progressive diseases of the skin or subcutaneous tissue, such as pemphigus and epidermolysis bullosa, which;
(1) Are disabling or life-threatening; and
(2) Require multidisciplinary management;
(b) Scars when surgery is required and at least one of the following criteria is met:
(1) There is limitation of or loss of mobility of a major joint, such as the ankle, knee, hip, wrist, elbow, or shoulder; or
(2) They are disabling or severely disfiguring.
(c) Congenital anomalies of the skin or subcutaneous tissue that meet the criteria of section 41518.8.
Section 41518.7: Diseases of the Musculoskeletal System and Connective Tissue (ICD-10 M00-M99)
(a) CCS applicants with at least one of the following conditions shall be medically eligible for participation in the CCS program:
(1) Acute and chronic suppurative infections of the joint;
(2) Chronic, progressive or recurrent inflammatory disease of the connective tissue or joints, such as rheumatoid arthritis, inflammatory polyarthropathy, lupus erythematosus, dermatomyositis, and scleroderma;
(3) Chronic, progressive, or degenerative diseases of muscles and fascia, such as myasthenias, myotonias, dystrophies, and atrophies that lead to atrophy, weakness, contracture and deformity, and motor disability;
(4) Intervertebral disc herniation;
(5) Scoliosis with a curvature of 20 degrees or greater;
(6) Other disease of the bones and joints, except fractures, resulting in limitation of normal function and requiring surgery, complex customized bracing, or more than two castings; or
(7) Congenital anomalies of the musculoskeletal system or connective tissue that meet the criteria of section 41518.8.
(b) Minor orthopedic conditions, such as tibia torsion, femoral anteversion, knock knees, pigeon toes, and flat feet, which only require special shoes, splints, and/or simple bracing are not eligible.
Section 41518.8: Congenital Anomalies (ICD-10 Q00-Q99)
(a) CCS applicants with congenital anomalies shall be medically eligible for participation in the CCS program when the congenital anomaly is amenable to cure, correction, or amelioration; and
(1) Limits or compromises a body function based on a combination of factors such as its size, type and location; or
(2) Is severely disfiguring.
(b) The following conditions shall not be medically eligible for the CCS program when the application for eligibility is based solely on their presence:
(1) Inguinal and umbilical hernia;
(3) Unilateral undescended testicle.
Section 41518.9: Accidents, Poisonings, Violence, and Immunization Reactions (ICD-10 S00-T88)
CCS applicants with at least one of the following conditions shall be medically eligible for participation in the CCS program:
(a) Injuries to organ systems or organs which, if left untreated, are likely to result in permanent physical disability, permanent loss of function, severe disfigurement or death;
(b) Fractures of the spine, pelvis, or femur;
(c) Fractures of the skull which, if left untreated, would result in Central Nervous System complications or severe disfigurement;
(d) All other fractures which require open reduction, internal fixation or which involve the joints or growth plates;
(e) Burns, when at least one of the following is present:
(1) Second and third degree burns of greater than 10 percent of the body surface area for children less than 10 years of age;
(2) Second and third degree burns of greater than 20 percent of the body surface area for children greater than 10 years of age;
(3) Third degree burns of greater than five percent of the body surface area for any age group;
(4) Burns involving signs or symptoms of inhalation injury or causing respiratory distress;
(5) Second or third degree burns of the face, ear, the mouth and throat, genitalia, perineum, major joints, the hands and feet; or
(6) Electrical injury or burns, including burns caused by lighting;
(f) Presence of a foreign body when the object, if not surgically removed, would result in death or a permanent limitation or compromise of a body function;
(g) Ingestion of drugs or poisons that result in life threatening events and require inpatient hospital treatment;
(h) Lead poisoning as defined as a confirmed blood level of 20 micrograms per deciliter or above;
(i) Poisonous snake bites that require complex medical management and that may result in severe disfigurement, permanent disability or death;
(j) Other envenomation, such as spider bites, that require complex medical management and that may result in severe disfigurement, permanent disability or death; or
(k) Severe adverse reactions to an immunization requiring extensive medical care.
Perinatal Morbidity and Mortality (ICD-10 P00-P96)
Neonates who have a CCS-eligible condition and require care in a CCS-approved neonatal intensive care unit (NICU) because of the eligible condition.
Critically ill neonates who do not have an identified CCS-eligible condition but who require one or more of the following services in a CCS-approved NICU:
- Invasive or non-invasive positive ventilatory assistance.
- Supplemental oxygen concentration by hood of greater than or equal to 40 percent.
- Maintenance of an umbilical artery (UA) or peripheral arterial catheter (PAC) for medically necessary indications, such as monitoring blood pressure or blood gases.
- Maintenance of an umbilical venous catheter or other central venous catheter for medically necessary indications, such as pressure monitoring or cardiovascular drug infusion.
- Maintenance of a peripheral line for intravenous pharmacological support of the cardiovascular system.
- Central or peripheral hyperalimentation.
- Chest tube.
Neonates and infants who do not have an identified CCS-eligible condition but who require two or more of the following services in a CCS-approved NICU:
- Supplemental inspired oxygen.
- Maintenance of a peripheral intravenous line for administration of intravenous fluids, blood, blood products or medications other than those used in support of the cardiovascular system.
- Pharmacological treatment for apnea and/or bradycardia episodes.
- Tube feedings.
