LAC 40:I.3119
A. Maximum allowable reimbursement lists the maximum payment allowed for vision items described by HCPCS codes. Payment will be the least of:
3. the amount indicated in the maximum allowable reimbursement schedule.
| State of Louisiana Office of Workers' Compensation Schedule of Maximum Allowances for Vision Services and Supplies | ||
| HCPCS | Description | Purchase New |
| V2020 | Frames; Purchases | $74 |
| V2025 | Deluxe Frame | B.R. |
| V2100 | Sphere; Single Vision | $50 |
| V2101 | Sphere; Single Vision | $58 |
| V2102 | Sphere; Single Vision | $60 |
| V2103 | Spherocylinder; Single Vision | $38 |
| V2104 | Spherocylinder; Single Vision | $54 |
| V2105 | Spherocylinder; Single Vision | $57 |
| V2106 | Spherocylinder; Single Vision | $59 |
| V2107 | Spherocylinder; Single Vision | $65 |
| V2108 | Spherocylinder; Single Vision | $59 |
| V2109 | Spherocylinder; Single Vision | $59 |
| V2110 | Spherocylinder; Single Vision | $61 |
| V2111 | Spherocylinder; Single Vision | $63 |
| V2112 | Spherocylinder; Single Vision | $86 |
| V2113 | Spherocylinder; Single Vision | $78 |
| V2114 | Spherocylinder; Single Vision | $100 |
| V2115 | Lenticular; (Myodisc); per Lens | $101 |
| V2118 | Aniseikonic Lens; Single Vision | $85 |
| V2121 | Lenticular lens, per lens, single | $93 |
| V2199 | Not Otherwise Classified | B.R. |
| V2200 | Sphere; Bifocal | $66 |
| V2201 | Sphere; Bifocal | $66 |
| V2202 | Sphere; Bifocal | $92 |
| V2203 | Spherocylinder; Bifocal | $65 |
| V2204 | Spherocylinder; Bifocal | $69 |
| V2205 | Spherocylinder; Bifocal | $74 |
| V2206 | Spherocylinder; Bifocal | $83 |
| V2207 | Spherocylinder; Bifocal | $66 |
| V2208 | Spherocylinder; Bifocal | $91 |
| V2209 | Spherocylinder; Bifocal | $77 |
| V2210 | Spherocylinder; Bifocal | $87 |
| V2211 | Spherocylinder; Bifocal | $80 |
| V2212 | Spherocylinder; Bifocal | $89 |
| V2213 | Spherocylinder; Bifocal | $120 |
| V2214 | Spherocylinder; Bifocal | $125 |
| 2215 | Lenticular (Myodisc); per Lens | $93 |
| V2216 | Lenticular; Nonaspheric; per Lens | $91 |
| V2217 | Lenticular; Aspheric Lens; Bifocal | $108 |
| V2218 | Aniseikonic; per Lens; Bifocal | $105 |
| V2219 | Bifocal Seg Width over 28mm | $59 |
| V2220 | Bifocal Add over 3.25d | $60 |
| V2221 | Lenticular lens, per lens, bifocal | $109 |
| V2299 | Specialty Bifocal (by report) | B.R. |
| V2300 | Sphere; Trifocal | $81 |
| V2301 | Sphere; Trifocal | $104 |
| V2302 | Sphere; Trifocal | $101 |
| V2303 | Spherocylinder; Trifocal | $76 |
| V2304 | Spherocylinder; Trifocal | $82 |
| V2305 | Spherocylinder; Trifocal | $116 |
| V2306 | Spherocylinder; Trifocal | $124 |
| V2307 | Spherocylinder; Trifocal | $91 |
| V2308 | Spherocylinder; Trifocal | $92 |
| V2309 | Spherocylinder; Trifocal | $94 |
| V2310 | Spherocylinder; Trifocal | $98 |
| V2311 | Spherocylinder, Trifocal | $109 |
| V2312 | Spherocylinder; Trifocal | $101 |
| V2313 | Spherocylinder; Trifocal | $105 |
| V2314 | Spherocylinder; Trifocal | $111 |
| V2315 | Lenticular; (Myodisc); per Lens | $118 |
| V2316 | Lenticular Nonaspheric; per Lens | $111 |
| V2317 | Lenticular; Aspheric Lens | $138 |
| V2318 | Aniseikonic Lens; Trifocal | $156 |
| V2319 | Trifocal Seg Width over 28mm | $75 |
| V2320 | Trifocal Add over 3.25d | $84 |
| V2321 | Lenticular lens, per lens, trifocal | $145 |
| V2399 | Specialty Trifocal (by report) | B.R. |
| V2410 | Variable Asphericity Lens | $147 |
| V2430 | Variable Asphericity Lens; Bifocal | $141 |
| V2499 | Variable Sphericity Lens | B.R. |
| V2500 | Contact Lens; PMMA; Spherical | $125 |
| V2501 | Contact Lens; PMMA; Toric or Prism | $134 |
| V2502 | Contact Lens PMMA; Bifocal | $154 |
| V2503 | Contact Lens PMMA; Color Vision | $145 |
| V2510 | Contact Lens; Gas Permeable | $171 |
| V2511 | Contact Lens; Gas Permeable; Toric | $186 |
| V2512 | Contact Lens; Gas Permeable | $277 |
| V2513 | Contact Lens; Gas Permeable | $252 |
| V2520 | Contact Lens Hydrophilic | $128 |
| V2521 | Contact Lens Hydrophilic; Toric | $193 |
| V2522 | Contact Lens Hydrophillic; Bifocal | $262 |
| V2523 | Contact Lens Hydrophilic; Extended | $181 |
| V2530 | Contact Lens; Scleral; per Lens | $277 |
| V2531 | Contact lens, scleral, gas permeable, per lens | $783 |
| V2599 | Contact Lens; Other Type | B.R. |
| V2600 | Hand Held Low Vision Aids | B.R. |
| V2610 | Single Lens Spectacle Mounted | B.R. |
| V2615 | Telescopic and Other Compound Lens | B.R. |
| V2623 | Prosthetic Eye; Plastic; Custom | $1,384 |
| V2624 | Polishing Artificial Eye | $78 |
| V2625 | Enlargement of Ocular Prosthesis | $374 |
| V2626 | Reduction of Ocular Prosthesis | $259 |
| V2627 | Scleral Cover Shell | $1,412 |
| V2628 | Fabrication and Fitting | $367 |
| V2629 | Prosthetic Eye; Other Type | B.R. |
| V2630 | Anterior Chamber Intraocular Lens | $534 |
| V2631 | Iris Supported Intraocular Lens | $534 |
| V2632 | Posterior Chamber Intraocular Lens | $453 |
| V2700 | Balance Lens; per Lens | $52 |
| V2702 | Deluxe lens feature | B.R. |
| V2710 | Slab off Prism; Glass or Plastic | $78 |
| V2715 | Prism; per Lens | $19 |
| V2718 | Press-on Lens; Fresnell Prism | $41 |
| V2730 | Special Base Curve | $33 |
| V2744 | Tint; Photochromatic; per Lens | $20 |
| V2745 | Addition to lens; tint, any color, solid, gradient or equal, excludes photochromatic, any lens material, per lens | $13 |
| V2750 | Anti-Reflective Coating; per Lens | $26 |
| V2755 | UV Lens; per Lens | $27 |
| V2756 | Eye glass case | $6 |
| V2760 | Scratch Resistant Coating | $17 |
| V2761 | Mirror coating, any type, solid, gradient or equal, any lens material, per lens | B.R. |
| V2762 | Polarization, any lens material, per lens | B.R. |
| V2770 | Occluder Lens; per Lens | $29 |
| V2780 | Oversize Lens; per Lens | $15 |
| V2781 | Progressive lens, per lens | B.R. |
| V2782 | Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate, per lens | $71 |
| V2783 | Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass, excludes polycarbonate, per lens | $80 |
| V2784 | Lens, polycarbonate or equal, any index, per lens | $52 |
| V2785 | Processing; Transp Corneal Tissue | B.R. |
| V2786 | Specialty occupational multifocal lens, per lens | B.R. |
| V2787 | Astigmatism correcting function of intraocular lens | B.R. |
| V2790 | Amniotic membrane for surgical reconstruction, per procedure | B.R. |
| V2797 | Vision supply, accessory and/or service component of another hcpcs vision code | B.R. |
| V2799 | Vision Service; Miscellaneous | B.R. |
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.
HISTORICAL NOTE: 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), amended by the Workforce Commission, Office of Workers’ Compensation, LR 39:1840 (July 2013).