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Prescribed Pediatric Extended Care (for Kentucky Only)
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Policy governing coverage and medical necessity criteria for Prescribed Pediatric Extended Care (PPEC) services for UnitedHealthcare Community Plan members in Kentucky.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Medical Necessity Criteria
Covered when ALL of the following are met:
Refer to KAR for full clinical criteria
Leveling Tool available on request
This policy notes that Prescribed Pediatric Extended Care is not regulated by the FDA. This statement is informational only and is not intended as an exclusion of services or a coverage determination; it clarifies that FDA regulation does not apply to this type of pediatric extended care.
The policy does not include any explicit statements that services are not medically necessary. No procedures or conditions are listed in the document as expressly non-covered on the basis of medical necessity.
Procedure Codes, Modifiers, and Leveling
| T1025 | Intensive, extended multidisciplinary services provided in a clinic setting to children with complex medical, physical, mental and psychosocial impairments, per diem |
| T1026 | Intensive, extended multidisciplinary services provided in a clinic setting to children with complex medical, physical, mental, and psychosocial impairments, per hour |
| TT | Level of Care = Individualized service provided to more than one patient in same setting |
| TF | Level of Care = Intermediate level of care |
| TG | Level of Care = Complex/high tech level of care |
Authorization, Documentation, and Operational Steps for Providers
Prior authorization required; update every 6 months and assign Level of Care before admission
Authorization is required and must be updated every 6 months. Requests for admission must have an assigned Level of Care prior to admission using the Prescribed Pediatric Extended Care Leveling Evaluation Tool.
Complete and retain leveling evaluation prior to admission
Ensure the Leveling Evaluation Tool is completed and retained before admission and include Level of Care in authorization requests; the tool is available to providers on request.
- Assign Level 1–4 based on tool score thresholds (Level 1: 12–16; Level 2: 17–32; Level 3: 33–48; Level 4: 49+).
Documentation required for reauthorization every 6 months
For reauthorization every 6 months submit all required documentation: a PCP reevaluation within 30 days of the reauthorization and an updated PCP recommendation, among other items listed below.
- Reevaluation by the member's PCP within 30 days of reauthorization.
- Updated recommendation from the PCP.
- Updated parent/guardian consent form signed and witnessed prior to admission.
- Updated Provision of Services with supporting documentation.
- Documentation of the member's Level of Care.
Assign Level of Care with the Prescribed Pediatric Extended Care Leveling Evaluation Tool before admission
An appropriate Level of Care must be assigned prior to admission using the Prescribed Pediatric Extended Care Leveling Evaluation Tool; the tool is available to providers on request.
- Levels are defined by score ranges: Level 1 (12–16), Level 2 (17–32), Level 3 (33–48), Level 4 (49+).
- Include the assigned Level of Care in the authorization submission.
Denial risk if renewal documentation is not submitted
Failure to submit the required renewal documentation may result in denial of reauthorization; providers must submit all items listed at each 6‑month renewal.
- Required at renewal: PCP reevaluation within 30 days of reauthorization; updated PCP recommendation; updated signed consent; updated Provision of Services with supporting documentation; documentation of the member's Level of Care.
Background and Scope
Prescribed Pediatric Extended Care (PPEC) provides intensive, multidisciplinary services in a clinic setting for children with complex medical, physical, mental, and psychosocial impairments who are medically or technologically dependent. Services are delivered at varying intensities determined by an assigned Level of Care (Levels 1–4), which must be assigned prior to admission using the Prescribed Pediatric Extended Care Leveling Evaluation Tool. The leveling thresholds are: Level 1: 12–16; Level 2: 17–32; Level 3: 33–48; Level 4: 49+. Coverage and medical necessity are governed by Kentucky Administrative Regulations (KAR), § 902-020-280, and members must meet the clinical criteria established by those regulations for PPEC to be considered medically necessary and covered under this policy.
Key Definitions
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