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, Part 2, Subdivision 7, CCS, Chapter 4, Medical Eligibility, Sections 41800-41872 for full description. The applicable medical eligibility section is noted with each category below.

A. Infectious Diseases (ICD-9-CM 001-139 & ICD-10 A00-B99) (Section 41811)

In general, these conditions are eligible when they:

• involve the central nervous system and produce disabilities requiring surgical and/or rehabilitation services;
• involve bone;
• involve eyes leads to blindness;
• are congenitally acquired and for which postnatal treatment is required and appropriate.

B. Neoplasms (ICD-9-CM 140-239 & ICD-10 C00-D49) (Section 41815)

All malignant neoplasms, including those of the blood and lymph systems.

Benign neoplasms when they constitute a significant disability, visible deformity, or significantly interfere with function.

C. Endocrine, Nutritional, and Metabolic Diseases, and Immune Disorders (ICD-9-CM 240-279 & ICD-10 E00-E89) (Section 41819)

In general, these conditions are eligible. Examples of eligible conditions include diseases of the pituitary, thyroid, parathyroid, adrenal, pancreas, ovaries and testes; growth hormone deficiency, diabetes mellitus, diseases due to congenital or acquired immunologic deficiency manifested by life-threatening complications, various inborn errors of metabolism; cystic fibrosis.

Nutritional disorders such as failure to thrive and exogenous obesity are not eligible.

D. Diseases of Blood and Blood-Forming Organs (ICD-9-CM 280-289 & ICD-10 D50-D89) (Section 41823)

In general, these conditions are eligible. Common examples of eligible conditions are: sickle cell anemia, hemophilia, and aplastic anemia.

Iron or vitamin deficiency anemias are only eligible when there are life-threatening complications.

E. Mental Disorders and Mental Retardation (ICD-9-CM 290-319 & ICD-10 F01-F99) (Section 41827)

Conditions of this nature are not eligible except when the disorder is associated with or complicates an existing CCS-eligible condition.

F. Diseases of the Nervous System (ICD-9-CM 320-389 & ICD-10 G00-G99) (Section 41831)

Diseases of the nervous system are, in general, eligible when they produce physical disability (e.g., paresis, paralysis, ataxia) that significantly impair daily function.

Idiopathic epilepsy is eligible when the seizures are uncontrolled, as per regulations. Treatment of seizures due to underlying organic disease (e.g., brain tumor, cerebral palsy, inborn errors of metabolism) is based on the eligibility of the underlying disease.

Specific conditions not eligible are those which are self-limiting and include acute neuritis and neuralgia; and meningitis that does not produce sequelae or physical disability. Learning disabilities are not eligible.

G. Diseases of the Eye (ICD-9-CM 360-379 & ICD-10 H00-H59) (Section 41835)

Strabismus is eligible when surgery is required.

Chronic infections or diseases of the eye are eligible when they may produce visual impairment and/or require complex management or surgery.

H. Diseases of the Ear and Mastoid (ICD-9-CM 380-389 & ICD-10 H60-H95) (Section 41839)

• Hearing loss, as defined per regulations;
• Perforation of the tympanic membrane requiring tympanoplasty;
• Mastoiditis;
• Cholesteatoma.

I. Diseases of the Circulatory System (ICD-9-CM 390-459 & ICD-10 I00-I99) (Section 41844)

Conditions involving the heart, blood vessels, and lymphatic system are, in general, eligible.

J. Diseases of the Respiratory System (ICD-9-CM 460-519 & ICD-10 J00-J99) (Section 41848)

Lower respiratory tract conditions are eligible if they are chronic, cause significant disability, and respiratory obstruction; or complicate the management of a CCS-eligible condition.

Lungs: chronic lung disease of infancy is eligible; chronic lung disease of immunologic origin is eligible, as per regulations.

K. Diseases of the Digestive System (ICD-9-CM 520-579 & ICD-10 K00-K95) (Section 41852)

Diseases of the liver, chronic inflammatory disease of the gastrointestinal (GI) tract and most congenital abnormalities of the GI system are eligible; and gastroesophageal reflux, as per regulations.

Malocclusion is eligible when there is severe impairment of occlusal function and is subject to CCS screening and acceptance for care.

L. Diseases of the Genitourinary System (ICD-9-CM 580-629 & ICD-10 N00-N99) (Section 41856)

Chronic genitourinary conditions and renal failure are eligible. Acute conditions are eligible when complications are present.

M. Diseases of the Skin and Subcutaneous Tissues (ICD-9-CM 680-709 & ICD-10 L00-L99) (Section 41864)

These conditions are eligible if they are disfiguring, disabling, and require plastic or reconstructive surgery and/or prolonged and frequent multidisciplinary management.

N. Diseases of the Musculoskeletal System and Connective Tissue (ICD-9-CM 710-739 & ICD-10 M00-M99) (Section 41866)

Chronic diseases of the musculoskeletal system and connective tissue are eligible. Minor orthopedic conditions such as toeing-in, knock knee, and flat feet are not eligible. However, these conditions may be eligible if expensive bracing, multiple casting, and/or surgery is required. See Q. below for acute injuries.

O. Congenital Anomalies (IDC-9-CM 740-759 & ICD-10 Q00-Q99) (Section 41868)

Congenital anomalies of the various systems are eligible if the condition limits a body function, is disabling or disfiguring, amenable to cure, correction, or amelioration, as per regulations.

P. Perinatal Morbidity and Mortality (ICD-9-CM 760-779 & 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.

Q. Accidents, Poisonings, Violence, and Immunization Reactions (ICD-9-CM 800-999 & ICD-10 S00-T88) (Section 41872)

Injuries of the central or peripheral nervous and vital organs may be eligible if they can result in permanent disability or death. Fractures of the skull, spine, pelvis, or femur which when untreated would result in permanent loss of function or death. Burns, foreign bodies, ingestion of drugs or poisons, lead poisoning, and snake bites may be eligible, as per regulations.