Arkansas Code Title 23. Public Utilities and Regulated Industries § 23-79-1502. Craniofacial anomaly--Coverage for reconstructive surgery required

(a)(1) A health benefit plan that is offered, issued, provided, or renewed in this state shall include coverage and benefits for reconstructive surgery and related medical care for a person of any age who is diagnosed as having a craniofacial anomaly if the surgery and treatment are medically necessary to improve a functional impairment that results from the craniofacial anomaly as determined by a nationally approved cleft-craniofacial team, approved by the American Cleft Palate-Craniofacial Association in Chapel Hill, North Carolina.

(2) A nationally approved cleft-craniofacial team for cleft-craniofacial conditions shall:

(3) After one (1) denial or any limitation of coverage that is based on the lack of medical necessity to improve a functional impairment, the case shall be referred for an external review under State Insurance Department Rule 76, the Arkansas External Review Regulation, if applicable, or under a similar procedure for external review established by a third-party administrator of a health benefit plan.

(c)(1) The services included in the coverage described in subsection (b) of this section shall be authorized by a surgical member of a nationally approved cleft-craniofacial team of the American Cleft Palate-Craniofacial Association.

(2) For healthcare services to be performed by a nationally approved cleft-craniofacial team, a request for written authorization or approval shall be reviewed by the administrator of the health benefit plan:

(1) On an annual basis:

(3) Every four (4) years, a dehumidifier.

(e)(1) A nationally approved cleft-craniofacial team that is located in other states may provide the healthcare services, treatment, evaluation, authorizations, and review as described in this section.

(2) For healthcare services performed outside of this state under this section, the insured or enrollee shall not be penalized for out-of-network charges subject to the terms and conditions of the health benefit plan.