Rule 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 an injured worker requires the purchase or repair of an artificial appliance as determined by any one of the following:
(1) 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.
(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 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.
Last updated February 1, 2022 at 9:39 AM
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