10A NCAC 39A .1106. MEDICAL ELIGIBILITY

(a)  To be medically eligible for diagnostic authorization, a patient must have a condition strongly suspicious of cancer which requires diagnostic services to confirm the preliminary diagnosis.  The Program shall authorize only those services determined by the program to be medically necessary to confirm a preliminary diagnosis.

(b)  Diagnostic services for suspected cervical intraepithelial neoplasia shall be covered by the Program if there is cytologic evidence suggestive of cervical intraepithelial neoplasia.

(c)  A positive pathology report shall be required before treatment services can be authorized by the Program.

(d)  Before treatment services may be authorized, the attending physician must certify that there is a 25 percent or better chance of five-year survival with treatment.  The Program shall use the current five-year relative survival rates published by the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program as a guide for evaluating requests for treatment.  These rates are incorporated herein by reference in accordance with G.S. 150B-21.6, along with any subsequent amendments and editions.  They may be used by physicians to assist with estimating survival.  Copies of the rates may be obtained at no cost by calling [phone] or by writing to the Cancer Control Program, 1915 Mail Service Center, Raleigh, North Carolina 27699-1915.

(e)  All requests for treatment shall be reviewed by the Program.  Such requests shall be authorized when the Program determines that there is at least a 25 percent chance of five-year survival with treatment and that the services to be provided are medically necessary to improve the chance of survival.  In determining medical eligibility, the Program may confer with the patient's attending physician, members of the Cancer Committee of the North Carolina Medical Society, and other physicians trained in the treatment of cancer.

(f)  All requests for chemotherapy shall be accompanied by a protocol describing the treatment being requested.

 

History Note:        Filed as a Temporary Adoption Eff. December 1, 1992 for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Authority G.S. 130A‑205;

Eff. April 1, 1993;

Amended Eff. August 1, 2000; August 1, 1995.