Rule 4123-6-31 | Payment for miscellaneous medical services and supplies.
(A) Acupuncture.
Acupuncture is eligible for reimbursement when prior authorized and administered by a licensed doctor of medicine, doctor of osteopathic medicine and surgery, or doctor of podiatric medicine, a doctor of chiropractic who holds a certificate to practice acupuncture from the Ohio state chiropractic board, or a non-physician acupuncturist licensed pursuant to and practicing in compliance with Chapter 4762. of the Revised Code.
(B) Orthotic devices.
(1) Payment is made only for those orthotic devices prescribed in writing by the physician of record or treating physician for treatment of an allowed injury or occupational disease.
(2) Orthotic devices are eligible for reimbursement only when 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 will be made within sixty days of fitting and application without additional charge by the supplier of the orthotic device.
(3) Measurement, transportation, or other expenses incurred by the supplier-orthotist are not eligible for reimbursement, except when the supplier-orthotist needs to travel beyond the limits of the metropolitan community in which they maintain their 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 in those circumstances will be paid for traveling expenses on a round-trip basis when 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.
(C) Dental care.
(1) Payment for dental care will be made in the following cases:
(a) Where the work related accident causing the injury also results in the damage or loss of the injured worker's artificial teeth or other denture. Once the artificial teeth or other denture(s) have been repaired, replaced, or adjusted, no further repair, replacement, or adjustment will be approved.
(b) Where a work related injury or occupational disease has caused damage or adversely affected the injured worker's natural teeth.
(2) 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 caused by an allowed injury or occupational disease.
(D) Eyeglasses and contact lenses.
(1) Payment for eyeglasses or contact lenses will be made in the following cases:
(a) Where the work related accident causing the injury also results in the damage or loss of the injured worker's eyeglasses or contact lenses. Once the eyeglasses or contact lenses have been repaired, replaced, or adjusted, no further repair, replacement, or adjustment will be approved.
(b) Where loss of vision is the result of an allowed injury or occupational disease.
(2) Refractions will be approved in situations described in paragraph (D)(1)(b) of this rule.
(3) When medical evidence indicates a need due to an allowed injury or occupational disease contact lenses may be approved instead of eyeglasses.
(4) Glasses or contact lenses will be approved for treatment purposes, when necessary, as a result of the allowed injury or occupational disease. Any subsequent adjustment or change in an injured worker's glasses or contact lenses, if medically necessary for treatment of the allowed injury or occupational disease, will also be approved.
(E) Hearing aids.
Payment for hearing aids will be made in the following cases:
(1) Where the work related accident causing the injury also results in the damage or loss of the claimant's hearing aid(s) Once the hearing aid(s) have been repaired, replaced, or adjusted, no further repair, replacement or adjustment will be approved.
(2) When a partial loss of hearing is the result of an allowed injury or occupational disease.
(F) Diagnostic testing, nerve injections, and imaging.
(1) Requests for diagnostic electromyography (EMG), nerve conduction study (NCS), epidural injections, nerve blocks, and medical imaging will be reimbursed when medical evidence shows that the diagnostic EMG, NCS, epidural injection, nerve block, or medical imaging is medically necessary either to develop a plan of treatment for, or to pursue more specific diagnoses reasonably related to, an allowed condition and the criteria of paragraphs (B)(1) to (B)(3) of rule 4123-6-16.2 of the Administrative Code are met.
(2) When the results of the diagnostic EMG, NCS, epidural injections, nerve block, or medical imaging indicate a non-allowed condition, therapeutic treatment for such non-allowed condition will not be reimbursed unless the condition is additionally allowed in the claim.
(3) Requests for duplicative diagnostic EMG, NCS, or medical imaging will not be reimbursed absent evidence of new or changed medical circumstances since the last diagnostic EMG, NCS, or medical imaging, or other medical evidence supporting the need for additional diagnostic testing or imaging that meets the criteria of paragraphs (B)(1) to (B)(3) of rule 4123-6-16.2 of the Administrative Code.
(4) With medical evidence supporting the necessity, reimbursement for diagnostic epidural injections or nerve blocks:
(a) May include up to three spinal levels, unilaterally or bilaterally, contiguous to the level of the allowed condition; and
(b) May include one repeat diagnostic injection to confirm a pain relief response prior to submission of requests for reimbursement of therapeutic treatment at the allowed level.
(5) Medical imaging includes magnetic resonance imaging (MRI), computed tomography scan (CT), discogram, positron emission tomography (PET), myelogram, X-ray, and ultrasound.
(G) Once payment for orthotic devices, artificial teeth or other dentures, eyeglasses, contact lenses, or hearing aids has been made, replacement requests may be denied in instances of malicious damage, neglect, culpable irresponsibility, or wrongful disposition.
Last updated June 3, 2024 at 8:32 AM
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