Louisiana Administrative Code
Title 40 - LABOR AND EMPLOYMENT
Part I - Workers' Compensation Administration
Subpart 2 - Medical Guidelines
Chapter 43 - Prosthetic and Orthopedic Equipment
Section I-4313 - Nonlisted Items and Individual Consideration

A. Occasionally, there may be a workers' compensation claim where the HCPCS code either does not appear on the Schedule of Maximum Allowances or is designated as "By Report (BR)." In these instances where medical necessity has been documented, the carrier/self-insured employer should contact three prosthetic and orthotic equipment suppliers in the geographic area from which the claim originated and obtain charge information for the specific HCPCS code billed. The carrier will use the average of the three responses as the maximum allowance for the specific HCPCS code. This procedure may be repeated when necessary for other codes which fall into this category.