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CHAPTER 3 Covered and Excluded CRS Conditions
The CRS program is based on an individual’s need for treatment of CRS conditions through
medical, surgical or therapy modalities where specialized treatment is necessary, functional
improvement is potentially achievable and long-term follow-up may be required for
maximum achievable results. A CRS covered condition is a condition or disease that qualifies
for treatment in the CRS program if other requirements are met. An excluded condition is not
covered by CRS.
COVERED CRS CONDITIONS
Cardiovascular system conditions covered by CRS include the following:
-Arrhythmias
-Arteriovenous fistulas
-Cardiomyopathies
-Conduction defects
-Congenital hart disease
-Kawasaki Disease with evidence of coronary artery aneurysm
-Renal vascular hypertension, catecholamine hypertension
-Rheumatic Heart disease that is not in the acute state
-Valvular disorders
Endocrine systems conditions covered by CRS include the following:
-Addison’s Disease
-Adrenogenital syndromes
-Cystic Fibrosis
-Diabetes Insipidus
-Hyperparathyroidism
-Hypoparathyroidism
-Hyperthyroidism
-Hypothyroidism
-Panhypopitutitarism
Genitourinary system conditions covered by CRS include the following:
-Ambiguous genitalia
-Complex hypospadias
-Deformity and dysfunction of the genitourinary system secondary to trauma.
-Once the acute phase of the trauma has passed, CRS covers the corrective
component of the deformity or dysfunction.
-Ectopic ureter
-Multicystic Dysplastic Kidneys
-Nephritis associated with lupus erythematosis
-Obstructive urpathy hydronephrosis
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-Pyelonephritis which has failed medical management and requires surgical
intervention
-Ureteral stricture
-Vesicoureteral reflux, grade III or greater
Ear, Nose and Throat conditions covered by CRS include the following:
-Cholesteatoma
-Chronic mastoiditis
-Congenital malformations
-Craniofacial anomalies that require multi-specialty, interdisciplinary
treatments.
-Deformity and dysfunction of the ear, nose, or throat secondary to trauma.
-Once the acute phase of the trauma has passed, CRS covers the
corrective component of the deformity or dysfunction.
-Microtia that is grossly deforming as determined by physician medical review.
-Neurosensory hearing loss
-Otis media in a child with cleft lip and palate or neurosensory hearing loss
-Significant conductive hearing loss (greater than or equal to 30 decibels)
which despite medical treatment requires a hearing augmentation device.
Musculoskeletal System Conditions covered by CRS include the following:
- Osteochondrodysplasias, Including:
 Achondroplasia
 Hypochondroplasia
 Diastrophic dysphasia
 Chondrodysplasia
 Spondyloepiphyseal dysplasia and variants
 Metaphyseal and epiphyseal dysplasias
 Larsen Syndrome
 Fibrous dysplasia
 Osteogenesis imperfecta
 Rickets: all variants
 Enchondromatosis, multiple cartilaginous, exostoses, single
exostosis with evidence of functional impairment or rapid
enlargement
 Other osteochondrodysplasia as determined by Regional Medical
Director review
-Juvenile rheumatoid arthritis and seronegative spondyloarthropathies
-Orthopedic complications of hemophilia
-Neuromuscular conditions, including
 Myopathies
 Muscular dystrophies
 Myoneural disorders
 Arthrogryposis
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Spinal muscle atrophy
Polyneuropathies, including Guillain Barre after the acute stage
-Bone and joint infections (chronic stage)
-Upper Limb malformations
-Amputations
-Syndactyly
-Spinal deformity, including:
-Kyphosis
-Scoliosis
-Congenital spinal deformity with functional loss
-Cervical spine abnormalities, congenital and developmental
-Lower limb malformation
-Hip dysplasia
-Slipped capital femoral epiphysis
-Legg-Calve-Perthes Disease
-Amputations, including prosthetic sequelae of cancer
-Metatarsus adductus
-Leg length discrepancy
-Metatarsus primus varus
-Dorsal bunions
-Complex bunions
-Collagen vascular diseases
-Benign bone tumors
-Deformity and dysfunction secondary to musculoskeletal trauma in a patient
15 years of age and under at the time of initial injury, where the deformity and
dysfunction is not in the acute phase. Once the acute phase of the trauma has
passed, CRS covers the corrective component of the deformity or dysfunction.
-Osgood Schlatter’s disease that has failed medical management
-Complicated flat foot, defined as a rigid foot, unstable subtalar joint or
significant calcaneus deformity
Gastrointestinal System conditions covered by CRS include the following:
-Tracheosesophageal fistula
-Anorectal atresia
-Hischsprungs disease
-Diaphragmatic hernia
-Gastroesophageal reflux which has failed medical management and requires
surgical intervention
-Deformity and dysfunction of the gastrointestinal system secondary to trauma.
Once the acute phase of the trauma has passed, CRS covers the corrective
component of the deformity or dysfunction.
-Biliary atresia
-Congenital atresia, stenosis, fistuli or rotational abnormalities of the
gastrointestinal tract
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-Cleft lip and cleft palate (either or both conditions may be present)
-Other congenital malformations of the gastrointestinal tract
-Omphalocele
-Gastroschisis
Nervous System conditions covered by CRS include the following:
-Uncontrolled seizure disorders, where there have been more than 2 seizures
with documented adequate blood levels of 1 or more medications
-Simple or controlled seizure disorders are covered when the child has no other
health insurance. AHCCCS/KidsCare/private insurance eligible individuals
will be treated through those provider networks.
-Cerebral Palsy
-Muscular dystrophies or other myopathies
-Myoneural disorders
-Neuropathies (hereditary and idiopathic)
-Central nervous system degenerative diseases
-Central nervous system malformations and structural abnormalities
-Hydrocephalus
-Craniosynostosis in a child less than 18 months of age of sagittal sutures or
unilateral coronal sutures, or multiple sutures
-Myasthenia gravis, congenital or acquired
-Benign intracranial tumor
-Benign intraspinal tumor
-Tourette’s Syndrome
-Residual dysfunction after resolution of an acute phase of vascular accident,
inflammatory condition, or infection of the central nervous system
-Myelomeningocele (Spina Bifada)
-Neurofibromatosis
-Deformity and dysfunction secondary to trauma in a patient 15 years of age
and under at the time of the initial injury. Once the acute phase of the trauma
has passed (acute phase includes acute rehabilitation), CRS coves the
corrective component of the deformity or dysfunction.
-Sequelae of near drowning, after the acute phase
-Sequelae of spinal cord injury, after the acute phase
Ophthalmological conditions covered by CRS include the following:
-Cataracts
-Glaucoma
-Disorders of the optic nerve
-Non-malignant enucleation and post-enucleation reconstruction
-Retinopathy of prematurity
-Disorders of the iris, ciliary bodies, retina, lens or cornea
-Simple refractive error and astigmatism are covered for the above conditions.
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Respiratory System conditions covered by CRS include the following:
-Anomalies of the larynx, trachea and bronchi that require surgery
-Nonmalignant obstructive lesions of the larynx, trachea and bronchi
Integumentary System conditions covered by CRS include the following:
-Craniofacial anomalies that require multispecialty interdisciplinary treatment
-Burn scars where the burn scar is functionally limiting
-Hemangioma where the hemangioma is functionally limiting
-Cystic hygroma
Genetic and metabolic conditions covered by CRS include the following:
-Amino acid and organic acidopathies
-Inborn errors of metabolism
-Storage diseases
-Metabolic conditions ascertained through the Arizona Newborn Screening
Program
-Phenylketonuria
-Homocystinuria
-Hypothyroidism
-Maple syrup urine disease
-Biotinidase deficiency
-If the Arizona Newborn Screening Program adds other metabolic conditions
to the screening panel, the CRS program will apply or additional funding
through the legislative budget process to cover the treatment of the added
conditions.
Hematologic conditions covered by CRS include the following:
-Sickle cell anemia and other hemoglobinopathy
-Pre and post operative iron deficiency anemia incurred as a result of a CRS
condition
EXCLUDED CRS CONDITIONS
Cardiovascular conditions that are excluded:
-Arteriovenous fistulas, which may be a problem cosmetically, but do not
cause cardiac failure or threaten loss of function.
-Essential hypertension
-Functional murmurs of no physiological significance, including peripheral
pulmonic stenosis.
-Premature atrial, nodal or ventricular contractions of no hemodynamic
significance.
Endocrine system conditions that are excluded:
-Diabetes mellitus (includes treatment of diabetes mellitus in a member with
cystic fibrosis)
-Isolated Growth Hormone Deficiency
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-Hypotituitarism encountered in the acute treatment of malignancies
-Precocious puberty
Genitourinary conditions that are excluded:
-Enuresis, unless the enuresis is secondary to a CRS condition
-Hydrocele, unless the hydrocele is associated with a ventriculo-peritoneal
(VP) shunt.
-Meatal Stenosis
-Nephritis, infectious or noninfectious except when associated with lupus
erythematosis
-Nephrosis (nephrotic syndrome)
-Phimosis
-Simple hypospadias defined as isolated glandular or coronal aberrant location
of the urethral meatus without curvature of the penis.
-Undescended testicle
Ear, Nose and Throat conditions that are excluded:
-Acute perforations of the tympanic membrane
-Adenoiditis
-Cranial or Temporal Mandibular Joint Syndrome
-Drooling, excessive salivation
-Hypertrophic lingual frenum
-Isolated preauricular tags and/or pits
-Nasal polyps, except for members with cystic fibrosis
-Obstructive apnea
-Recurrent otitis media without cleft lip and palate or without neurosensory
hearing loss
-Simple deviated nasal septum
-Sinusitis, except for members with cystic fibrosis
-Tonsillitis
Musculoskeletal System conditions that are excluded:
-Ingrown toenails, unless secondary to a CRS condition
-Back pain with no structural abnormalities
-Ganglion cysts
-Uncomplicated flat foot
-Fractures except in cases where the fracture is caused by the CRS condition
and treatment is part of the CRS condition
-Popliteal cysts
-Femoral anteversion and tibial torsion, unless 1) associated with a
neuromuscular disorder when the individual is under 8 years of age; or 2) the
individual is 8 years of age or older and has significant functional impairment
-Simple Bunions, unless secondary to the CRS condition
-Carpal Tunnel Syndrome, unless secondary to the CRS condition
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Gastrointestinal conditions that are excluded:
-Malabsorption Syndrome (Short Bowel Syndrome) except for member with
cystic fibrosis
-Crohn’s disease
-Hernias except for diaphragmatic hernia
-Ulcer disease
-Ulcerative colitis
-Intestinal polyps
-Pyloric stenosis
-Celiac Disease
Nervous System conditions that are excluded:
-Headaches
-Suspected seizure disorder
-Central apnea secondary to prematurity
-Near Sudden Infant Death Syndrome
-Febrile seizures
-Occipital plagiocephaly, either positional or secondary to lambdoidal
synostosis
-Trigonocephaly secondary to isolated metopic synostosis
-Spina bifida occulta
-Near drowning in the acute phase
-Spinal cord injury in the acute phase
Ophthalmologic conditions that are excluded:
-Simple refraction error, except for members with an eligible ophthalmologic
conditions
-Astigmatism, except for members with an eligible ophthalmologic
-Strabismus (with the exception of children with cerebral palsy
myelomeningocele, shunts and specific CRS eligible ophthalmologic
disorders)
-Ptosis
Respiratory System conditions that are excluded:
-Respiratory distress syndrome
-Asthma
-Allergies
-Bronchopulmonary dysplasia
-Emphysema
-Chronic Obstructive Pulmonary Disease
-Acute or chronic respiratory care for the neuromuscularly impaired
Integumentary System conditions that are excluded:
-Deformities without limitations to activities of daily living
-Simple nevi
-Skin tags
-Port wine stain
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-Craniofacial anomalies with cosmetic considerations only
-Sebaceous cysts
-Isolated malocclusions (without documented functional loss)
-Pilonidal cysts
-Ectodermal dysplasia
Hematologic conditions not covered by CRS include the following:
-Sickle cell anemia and other hemoglobinopathy are excluded conditions for an
adult (21 years of age and older).
OTHER EXCLUDED CONDITIONS OR SERVICES
Allergies
Anorexia and Obesity
-Eating disorders, including anorexia, bulimia, and obesity, are excluded
Autism
Burns
-Burns are excluded. However, a burn scar that limits functions or movement
may be a CRS condition (see Integumentary System Conditions)
Cancer/Oncology
Chronic Vegetative State or Profound Mental Retardation
-A chronic vegetative state or profound mental retardation is excluded a
primary diagnosis. These conditions are characterized by little or no
interaction with the environment and little or no likelihood of functional
improvement.
Deformity and Dysfunction Secondary to Trauma or Injury
-Coverage of deformity and dysfunction secondary to trauma or injury is
limited to children who are 15 years of age and under at the time of the initial
injury. The deformity or dysfunction must have passed the acute phase (at
least 3 months must have passed since the injury or trauma incident).
Dental and Orthodontia Services
-Dental services are excluded, except for treatment of the CRS members with
the following conditions:
Cleft lip or cleft palate
Documented significant functional malocclusion
Cardiac conditions where the member is at risk for subacute bacterial
endocarditis
Cerebral spinal fluid diversion shunt where the CRS member is at risk
for subacute bacterial endocarditis
Dental complications arising as a result of treatment for a CRS
condition
-Orthodontia services are excluded, except for treatment of CRS members with
the following conditions
Cleft lip or cleft palate
Documented significant functional malocclusion
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Depression or Other Mental Illness
-Depression or other mental illness is excluded unless the depression or other
mental illness is secondary to a CRS condition. If the depression or other
mental illness is related to a CRS condition, a therapeutic trial or medication is
allowed. Individual should be referred to an appropriate agency for ongoing
treatment.
Developmental Delay
Dyslexia/Learning Disabilities
-Dyslexia and other learning disabilities, educational handicaps, minimal
cerebral dysfunction and behavioral problems are excluded.
Failure to Thrive
Hyperactivity
-Hyperactivity, including Attention Deficit Disorder, is excluded
Ilizarov for Leg Lengthening
-Ilizarov for leg lengthening is excluded, except when there s a presence f, or
predicted leg length discrepancy of grater than or equal to 5 centimeters at
skeletal maturity
Immunodeficiency
-HIV (Human Immunodeficiency Virus)
-AIDS (Acquired Immune Deficiency Syndrome
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