(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.
(1) Acupuncture must be 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.
(2) Acupuncture treatment must be
prior authorized.
(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
shall be
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 shall
will 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
Measurement, transportation, or other expenses
incurred by the supplier-orthotist are not eligible for
reimbursement, except when the supplier-orthotist
is required
needs to travel beyond the limits of the metropolitan
community in which he maintains his
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 shall
in those
circumstances will be paid for traveling expenses on a round-trip
basis. Additional charges must be
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
required
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)
Medical
Diagnostic
testing, nerve injections, and imaging.
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.
(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.
Notes
Ohio Admin. Code
4123-6-31
Effective:
6/1/2024
Five Year Review (FYR) Dates:
2/1/2027
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: 02/12/1997, 10/14/2002, 10/10/2003, 02/14/2005, 09/22/2008,
02/01/2010, 11/13/2015, 02/01/2022
