4123-6-31 Payment for miscellaneous medical services and supplies.

 

 

 

4123-6-31                    Payment for miscellaneous medical services and supplies.

 

 

 

(A)  Acupuncture.

 

(1)     Acupuncture is a recognized method of treatment in Ohio and must be administered by a licensed doctor of medicine, doctor of osteopathic medicine and surgery, or doctor of podiatric medicine who has completed a course of study in acupuncture under the administration of an approved college of medicine, college of osteopathic medicine and surgery, or college of podiatric medicine, doctor of chiropractic who holds a certificate to practice acupuncture from the Ohio state chiropractic board or a registered non-physician acupuncturist. Such treatment must be prior authorized.

 

(2)    Services provided by a non-physician acupuncturist must be prescribed by persons licensed under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery or podiatry or Chapter 4743. of the Revised Code to practice chiropractic. A registered non-physician acupuncturist shall perform acupuncture under the general supervision of the injured worker's prescribing physician or chiropractic physician. General supervision does not require that the acupuncturist and the prescribing physician or chiropractic physician practice in the same office.

 

(B)  Braces, shoes, and other orthoticOrthotic devices.

 

(1)    Payment is made only for those orthotic devices prescribed in writing by the physician of record for treatment of an allowed injury or occupational disease. The use of the orthotic device must be directly related to the allowed industrial injury or occupational disease.

 

(2)   Orthotic devices shall be custom fitted or custom fabricated and delivered to the satisfaction of the prescribing physician and the administrative agencies. Repairs, modifications, and adjustments to secure satisfactory application of the orthotic appliance shall be made within sixty days of fitting and application without additional charge by the supplier of the orthotic device.

 

(3)    No charge shall be made for measurement, transportation, or other expenses incurred by the supplier-orthotist, except when the supplier-orthotist is required to travel beyond the limits of the metropolitan community in which he maintains his place of business by reason of the physical incapacity of the claimant or by reason of direct prescription by the attending physician. The supplier-orthotist shall be paid for traveling expenses on a round-trip basis. Additional charges must be separately specified on the supplier-orthotist's billing, including the points of travel and the name of the physician prescribing  the  travel.  Payment  will  be  made  for  a  maximum  of  three

 

 

 

round-trip calls.

(4) Once payment for the orthotic device has been made, replacement requests may be denied in instances of malicious damage, neglect, culpable irresponsibility or wrongful disposition.

(C)  Dental care.

(1)   Payment for dental care shall be made in the following cases:

(a)     Where an industrial injury or occupational disease either has caused damage or has adversely affected the claimant's natural teeth. Where an injury or industrial accident not only causes an injury, but also results in the damage or loss of the claimant's artificial teeth or other denture. Once the artificial teeth or other denture(s) have been repaired, replaced, or adjusted, no further replacement will be approved.

(b)   For industrial injuries or occupational diseases sustained prior to January 1, 1979, artificial teeth or other denture must be in place in the worker's mouth at the time of damage or loss.Where an industrial injury or occupational disease either has caused damage or has adversely affected the claimant's natural teeth. Once payment for the artificial teeth or other denture(s) has been made, replacement requests may be denied in instances of malicious damage, neglect, culpable irresponsibility or wrongful disposition.

(c) For industrial injuries or occupational diseases sustained on or after January 1, 1979, the requirements of paragraph (C)(1)(b) of this rule do not apply.

(2)     Responsibility for injuries or occupational diseases affecting the claimant's natural teeth is limited to the repair or replacement of those teeth actually injured at the time of the accident, or directly affected by the injury  or disease. This responsibility does not include the replacement of teeth which are extracted or repaired for purposes unrelated to the industrial injury or occupational disease.

(3) Replacement of artificial teeth when the injury or occupational disease has resulted in a deformity of the jaw to the extent that artificial teeth cannot be used, is subject to the limitations of paragraphs (C)(1)(b) and (C)(1)(c) of this rule.

(4)(3) Responsibility for the repair of both natural and artificial teeth is limited to

the damage done at the time of the accident, or to the damage directly caused by an allowed injury or occupational disease.

(D)  Eyeglasses and contact lenses.

(1)     Payment  Payment  for  eyeglasses  or  contact  lenses  shall  be  made  in  the following cases:

(a)     is approved to replace eyeglasses or contact lenses when Where an industrial injury or an industrial accident not only causes an injury, but also results in the damage or loss of the claimant's eyeglasses or contact lenses. Once the eyeglasses or contact lenses have been repaired, replaced, or adjusted, no further replacement will be approved.

(a) In the event of injury prior to January 1, 1979, the eyeglasses must be in place on the claimant's face or the contact lenses shall be in place in the claimant's eye(s) at the time of injury.

(b) In the event of injury on or after January 1, 1979, the requirements of paragraph (D)(1)(a) of this rule do not apply.

(2)(b) Contact lenses or glasses are reimbursed when Where loss of vision is the direct result of an allowed injury or occupational disease. Once payment for the eyeglasses or contact lenses has been made, replacement requests can be denied in instances of malicious damage, neglect, culpable irresponsibility or wrongful disposition.

(3)(2) Refractions will be approved in situations described in paragraph (D)(2) (D)(1)(b) of this rule.

(4)(3) Replacement of glasses with contact lenses is approved when medical evidence indicates a direct need due to an allowed injury or occupational disease.

(5)(4) Glasses or contact lenses will be approved for treatment purposes, when necessary, as a direct result of the allowed injury or occupational disease. Any subsequent adjustment, maintenance supplies or change in a claimant's glasses or contact lenses, if required for treatment of the allowed injury or occupational disease, will also be approved when supported by evidence of a direct causal relationship.

When eyeglasses and/or contact lenses were damaged or broken in an industrial accident in which an injury was sustained by the claimant and have been replaced, no further replacement will be approved due to subsequent

breakage or for any other reason, except as provided in this paragraph of this rule.

(E)  Hearing aids.

(1)   When Payment for hearing aid(s) should be made where an industrial injury or an industrial accident which not only causes an injury, but also damages

results in the damage or loss of

the claimant's hearing aid(s), payment to

replace the hearing aid(s) is approved as follows: Once the hearing aid(s) have been repaired, replaced, or adjusted, no further replacement will be approved.

(a) For injuries or accidents sustained prior to January 1, 1979, the hearing aid(s) must be in place in the claimant's ear(s) at the time of the injury or accident.

(b) For  injuries  or  accidents  sustained  on  or  after  January  1,  1979,  the requirements of paragraph (E)(1)(a) of this rule do not apply.

(c) Once hearing aid(s) have been replaced, no further replacement will be approved.

(2)   When a partial loss of hearing is the direct result of an allowed industrial injury or occupational disease, payment for a hearing aid(s) is justified in order to improve the claimant's ability to hear.

(F)   X-rays.

Payment for x-ray examinations (including CT, MRI, and discogram) shall be made when medical evidence shows that the examination is medically necessary either for the treatment of an allowed injury or occupational disease, or for diagnostic purposes to pursue more specific diagnoses in an allowed claim. Providers shall follow all prior authorization requirements in effect at the time when requesting authorization and payment for such studies.

Effective:                                                             11/13/2015

Five Year Review (FYR) Dates:                         08/26/2015 and 08/25/2020

CERTIFIED ELECTRONICALLY

Certification

11/02/2015

Date

Promulgated Under:                           119.03

Statutory Authority:                           4121.12, 4121.121, 4121.30, 4121.31, 4121.44,

4121.441, 4123.05, 4123.66

Rule Amplifies:                                  4121.12, 4121.121, 4121.44, 4121.441, 4123.66

Prior Effective Dates:                         2/12/97, 10/14/02, 10/10/03, 2/14/05, 9/22/08