Ohio Admin. Code 4123-6-39 - Payment for prosthetic device or other artificial appliances
(A) For purposes of
this rule:
(1) "Amputee clinic" means an
interdisciplinary group of professional providers led by a physician with a
specialty in physical medicine and rehabilitation, orthopedic surgery or
vascular surgery knowledgeable in the field of prosthetics and physical
disabilities, comprised of members that may include a podiatrist, physical
therapist, occupational therapist, kinesiotherapist, prosthetist and other
medical specialists that serves individuals requiring prosthetic
devices.
(2) "Artificial appliance"
means any item that replaces a body part or function of a body part of an
injured worker who has received a scheduled loss or facial disfigurement award
for that body part under division (B) of section
4123.57
of the Revised Code, and that the amputee clinic at the Ohio state university
medical center, the opportunities for Ohioans with disabilities agency, or a
multidisciplinary amputee clinic or prescribing physician approved by the
administrator or the administrator's designee determines is needed by the
injured worker. Examples of artificial appliances include, but are not limited
to, prosthetic devices, artificial eyes, wheelchairs, canes, crutches, walkers,
braces, etc.
(3) "Prosthetic
device" means a custom fabricated or fitted medical device that is a type of
artificial appliance used to replace a missing appendage or other external body
part. It includes an artificial limb, hand, or foot, but does not include
devices implanted into the body by a physician, artificial eyes, intraocular
lenses, dental appliances, ostomy products, cosmetic devices such as breast
prostheses, eyelashes, wigs, or other devices that do not have a significant
impact on the musculoskeletal functions of the body.
(B) In all cases arising under division (B)
of section
4123.57
of the Revised Code, the bureau will pay the cost of
purchasing or repairing an artificial appliance out of the surplus fund,
regardless of whether the artificial appliance is part of the injured worker's
vocational rehabilitation, or if the injured worker has, or will ever be able,
to return to work, if a claimant
an injured worker requires the purchase or repair
of an artificial appliance, as determined
by any one of the following: (1)
(1)
the
The amputee clinic at the Ohio state university
medical center; (2) the opportunities for Ohioans
with disabilities agency; (3) a multidisciplinary amputee clinic or prescribing
physician approved by the administrator or the administrator's designer, the
bureau shall pay the cost of purchasing or repairing the artificial appliance
out of the surplus fund. The purchase or repair is made regardless of whether
the artificial appliance is part of the claimant's vocational rehabilitation,
or if the claimant has, or will ever be able, to return to
work.
(2)
The opportunities for Ohioans with disabilities
agency;
(3)
A multidisciplinary amputee clinic or prescribing
physician approved by the administrator or the administrator's
designer.
(C) The
bureau is responsible for processing requests for artificial appliance and
travel expenses associated with the artificial appliance in all self-insured
claims. When a
an
artificial appliance is needed in a self-insured claim, the provider will
send a request for the artificial appliance and/or request for repair, as well
as the subsequent bills, to the bureau.
(D) It is the prosthetist's responsibility to
ensure that any prosthetic device fits properly for three months from the date
of dispensing. Any modifications, adjustments, or replacements within three
months from the date of dispensing are the responsibility of the prosthetist
who supplied the item and the bureau will not reimburse for those services. The
provision of these services by another provider will not be separately
reimbursed.
(E)
Once payment for the artificial appliance has been
made, replacement requests may be denied in instances of malicious damage,
neglect, culpable irresponsibility, or wrongful disposition.
(F)
The bureau will
not pay the cost of purchasing or repairing a prosthetic device that is
designed solely to enable the injured worker to engage in sports, hobbies, or
other recreational activities.
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.57, 4123.66
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.57, 4123.66
Prior Effective Dates: 02/12/1997, 02/14/2005, 02/01/2010, 11/13/2015
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(A) For purposes of this rule:
(1) "Amputee clinic" means an interdisciplinary group of professional providers led by a physician with a specialty in physical medicine and rehabilitation, orthopedic surgery or vascular surgery knowledgeable in the field of prosthetics and physical disabilities, comprised of members that may include a podiatrist, physical therapist, occupational therapist, kinesiotherapist, prosthetist and other medical specialists that serves individuals requiring prosthetic devices.
(2) "Artificial appliance" means any item that replaces a body part or function of a body part of an injured worker who has received a scheduled loss or facial disfigurement award for that body part under division (B) of section 4123.57 of the Revised Code, and that the amputee clinic at the Ohio state university medical center, the opportunities for Ohioans with disabilities agency, or a multidisciplinary amputee clinic or prescribing physician approved by the administrator or the administrator's designee determines is needed by the injured worker. Examples of artificial appliances include, but are not limited to, prosthetic devices, artificial eyes, wheelchairs, canes, crutches, walkers, braces, etc.
(3) "Prosthetic device" means a custom fabricated or fitted medical device that is a type of artificial appliance used to replace a missing appendage or other external body part. It includes an artificial limb, hand, or foot, but does not include devices implanted into the body by a physician , artificial eyes, intraocular lenses, dental appliances, ostomy products, cosmetic devices such as breast prostheses, eyelashes, wigs, or other devices that do not have a significant impact on the musculoskeletal functions of the body.
(B) In all cases arising under division (B) of section 4123.57 of the Revised Code, the bureau will pay the cost of purchasing or repairing an artificial appliance out of the surplus fund, regardless of whether the artificial appliance is part of the injured worker's vocational rehabilitation, or if the injured worker has, or will ever be able, to return to work, if a claimant an injured worker requires the purchase or repair of an artificial appliance, as determined by any one of the following: (1)
(1) the The amputee clinic at the Ohio state university medical center; (2) the opportunities for Ohioans with disabilities agency; (3) a multidisciplinary amputee clinic or prescribing physician approved by the administrator or the administrator's designer, the bureau shall pay the cost of purchasing or repairing the artificial appliance out of the surplus fund. The purchase or repair is made regardless of whether the artificial appliance is part of the claimant's vocational rehabilitation, or if the claimant has, or will ever be able, to return to work.
(2) The opportunities for Ohioans with disabilities agency;
(3) A multidisciplinary amputee clinic or prescribing physician approved by the administrator or the administrator's designer.
(C) The bureau is responsible for processing requests for artificial appliance and travel expenses associated with the artificial appliance in all self-insured claims. When a an artificial appliance is needed in a self-insured claim, the provider will send a request for the artificial appliance and/or request for repair, as well as the subsequent bills, to the bureau.
(D) It is the prosthetist's responsibility to ensure that any prosthetic device fits properly for three months from the date of dispensing. Any modifications, adjustments, or replacements within three months from the date of dispensing are the responsibility of the prosthetist who supplied the item and the bureau will not reimburse for those services. The provision of these services by another provider will not be separately reimbursed.
(E) Once payment for the artificial appliance has been made, replacement requests may be denied in instances of malicious damage, neglect, culpable irresponsibility, or wrongful disposition.
(F) The bureau will not pay the cost of purchasing or repairing a prosthetic device that is designed solely to enable the injured worker to engage in sports, hobbies, or other recreational activities.
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.57, 4123.66
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.57, 4123.66
Prior Effective Dates: 02/12/1997, 02/14/2005, 02/01/2010, 11/13/2015