La. Admin. Code tit. 40 § I-3117

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-3117 - Benefit Detail and Limitations

A. Certain items are not payable by the carrier/self-insured employer unless specifically justified on medical grounds or as a replacement for eyewear of like-quality damaged in an occupational accident. In other words, upgrades such as daily wear to extended wear contact lenses, or ordinary frames to designer frames are not reimbursable. If the claimant desires an upgrade, the carrier/self-insured employer should be billed for the frames or lenses which approximates the original item and the claimant must pay the difference.

B. The items subject to this limitation are:

1. sunglasses;

2. scratch resistant lenses;

3. antireflectant lenses;

4. photosensitive lenses; and

5. oversized lenses.

C.Covered Vision Care Services includes exams, lenses, frames, and contact lenses prescribed by a licensed physician (M.D. or D.O.), or by an optometrist (O.D.). Prior approval is required from the carrier/self-insured employer.

D. Lenses must be equal in quality to the first quality lenses series manufactured by American Optical, Bausch and Lomb, or Univis, and must meet Z80.1 or Z80.2 standards of the American National Standards Institute.

E. Standard eyeglass frames adequate to hold lenses which qualify for payment are covered. Any additional charges for "oversize" or designer frames are considered optional and are the claimant's liability.

F. Therapeutic contact lenses:

1. are covered if the patient's visual acuity cannot otherwise be corrected to 20/70 in the better eye;

2. are covered if they are the only effective treatment; and

3. include the fee for cleaning and storage kits.

G. The contact lens suitability exam:

1. is included in the dispensing fee if the claimant is able to wear contact lenses;

2. is payable as a separate expense if the claimant is unable to wear contact lenses.

H. Prism, slab-off prism, and special base curve lenses are covered when prescribed because of therapeutic necessity.

I. Payment for covered frames and lenses is based on the provider's net acquisition cost comprising the material costs and laboratory costs, and the dispensing fee.

1.Net Acquisition Cost includes the frame, the lens ground on both sides with the edges ground for placement in the frame, plus laboratory costs associated with mounting in the frame; and applicable sales tax. The components of net acquisition cost are:

a. material costs:

i. actual cost for materials, excluding charges for laboratory services;

ii. cost of lens blank purchased directly from the manufacturer or wholesaler; and

iii. rose tints or their equivalent, when prescribed for therapeutic reasons; and

b. laboratory costs;

i. includes grinding to prescription;

ii. safety hardening;

iii. drop ball testing;

iv. coating and edging;

v. application of tints when prescribed, if not provided by manufacturer;

vi. assembly; and

vii. laboratory overhead.

2.Dispensing Fee-the fee that compensates a provider for dispensing lenses and frames as specified under this program. The dispensing fee includes measuring and verifying the lens as well as selecting, fitting, and adjusting the frames. A separate dispensing fee would be applicable for single vision, bifocal, and trifocal lenses. Contact lenses and special lenses are given individual consideration based on reported details and circumstances.

J. The maximum allowable reimbursement for professional services described by CPT codes are contained in the CPT Code Reimbursement Manual.

La. Admin. Code tit. 40, § I-3117

Promulgated by the Department of Labor, Office of Workers' Compensation, LR 19:54 (January 1993), repromulgated LR 19:212 (February 1993), amended LR 20:1299 (November 1994).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.