such additional information as the Office may require to make a decision with respect to waiver. Failure to furnish the information within 30 days of request shall result in denial of waiver, and no further requests for waiver shall be entertained until such time as the requested information is furnished. Subpart E-Furnishing Medical § 10.400 Physician and medical services, etc. defined. (a) The term "physician" as used in subparts E and F of this part includes physicians (M.D. and D.O.), surgeons, podiatrists, dentists, clinical psychologists, optometrists, and chiropractors, within the scope of their practice as defined by State Law. The term "physician" includes chiropractors only to the extent that their reimbursable services are limited to treatment consisting of manual manipulation of the spine to correct a subluxation as demonstrated by X-ray to exist. A physician whose license to practice medicine has been suspended or revoked by a State licensing or regulatory authority is not a physician within the meaning of this section during the period of such suspension or revocation. (b) The term "duly qualified physician" as used in subparts E and F of this part includes any physician, as defined by paragraph (a) of this section, who has not been excluded under the provisions of subpart F of this part. Except as otherwise provided by regulation, a duly qualified physician shall be deemed to be designated or approved by the Office. (c) The term "duly qualified hospital" as used in subparts E and F of this part includes any hospital licensed as such under State law which has not been excluded under the provisions of subpart F of this part. Except as otherwise provided by regulation, a duly qualified hospital shall be deemed to be designated or approved by the Office. (d) The term “duly qualified provider of medical support services or supplies" as used in subparts E and F of this part includes any person, other than a physician or a hospital, who provides services, drugs, supplies, and appliances for which the Office makes payment who possesses any applicable licenses required under State law and who has not been excluded under the provisions of subpart F of this part. (e) The term "medical services" as used in subparts E and F of this part includes services and supplies provided by or under the supervision of physicians (M.D. and D.O.), surgeons, podiatrists, dentists, clinical psychologists, optometrists, and chiropractors, within the scope of their practices as defined by State law. Reimbursable chiropractic services are limited to treatment consisting of manual manipulation of the spine to correct a subluxation as demonstrated by x-rays to exist. Also included for payment or reimbursement are physical examinations (and related laboratory tests) and x-rays performed by or required by a chiropractor to diagnose a subluxation of the spinal column. The term “subluxation" means an incomplete dislocation, off-centering, misalignment, fixation or abnormal spacing of the vertebrae anatomically which must be demonstrable on any x-ray film to individuals trained in the reading of xrays. A chiropractor may interpret his or her x-rays to the same extent as any other physician defined in this section. (f) The term "hospital services" as used in subparts E and F of this part includes services and supplies provided by hospitals within the scope of their practice as defined by State law. (g) The term "medical support services and supplies" as used in subparts E and F of this part includes services, drugs, supplies, and appliances provided by a person other than a physican or hospital. (h) The term "job-related injury” as used in subparts E and F of this part includes injuries sustained while in the performance of duty and diseases proximately caused by the conditions of employment. (i) The term "designated agency official" means the individual delegated responsibility by an employing agency for authorizing medical treatment for the injured employee. [49 FR 18978, May 3, 1984, as amended at 52 FR 10520, Apr. 1, 1987] § 10.401 Medical treatment, hospital services, transportation, etc. (a) A claimant shall be entitled to receive all medical services, appliances or supplies which are prescribed or recommended by a duly qualified physician and which the Office considers necessary for the treatment of a job-related injury, whether or not the claimant is disabled. Such services, appliances and supplies may be furnished by, or on the order or recommendation of, either United States medical officers or hospitals, or, at the claimant's option as provided in paragraph (b) of this section, any other duly qualified physician or duly qualified hospital. Medical support services and supplies not furnished by a duly qualified physician or a duly qualified hospital shall be furnished by a duly qualified provider of medical support services or supplies. A claimant shall also be entitled to reimbursement of reasonable and necessary expenses, including transportation incident to obtaining authorized medical services, appliances or supplies. (b) A claimant has an initial choice of physicians. The designated agency official shall give the claimant an opportunity to select a duly qualified physician, after advising the claimant of those physicians excluded under the provisions of this part. An employee who wishes to change physicians must submit a written request to the Office fully explaining the reasons for the request. The Office may approve the request in its discretion if sufficient justification is shown for the request. Any duly qualified physician shall be authorized to provide necessary treatment of a job-related injury in an emergency. See also §10.456(c). (c) The medical facilities of the U.S. Public Health Service, Army, Navy, Air Force, and Veterans Administration may be used when previous arrangements have been made on a caseby-case basis with the director of the facility. (d) Federal health service units or other occupational health service facilities established under the provisions of the Act of August 8, 1946, as amended (U.S.C. 7901), are not U.S. medical hospitals as used in this part, nor are the staff of these facilities U.S. medical officers as used in this part. Under criteria established by the Bureau of the Budget (now the Office of Management and Budget) in Circular No. A-72 of June 18, 1965, these health service units or occupational health service facilities shall only provide emergency diagnosis and treatment of injury or illness such as are necessary during working hours and are within the competence of the professional staff of the health service unit or facility. Any medical treatments by these units or facilities other than emergency treatment must be specifically authorized by the Office and given under the supervision of a duly qualified physician. (e) Nothing in the Act or in these regulations affects any authority which the employing agency may have to require the employee to undergo a medical examination to determine whether the employee meets the mandatory medical requirements of the position held, or is able to perform the duties of the position held. Any agency-required examination or related activity shall not interfere with issuance of Form CA-16, with the employee's initial free choice of physician or with any authorized examination or treatment. (f) In emergency cases or those involving unusual considerations affecting the quality of medical care, the Office may authorize treatment or approve payment of medical expenses in a matter other than that provided in this subpart. [49 FR 18978, May 3, 1984] (b) To be valid, a Form CA-16 must give the full name and address of the duly qualified physician or duly qualified medical facility authorized to provide service, and must be signed and dated by the authorizing official, and must show his or her title. Except as provided in §10.404. Form CA-16 may not be issued for past medical care. The period for which treatment is authorized by a correctly issued Form CA-16 is limited to 60 days from the date of issuance, unless terminated earlier by the Office. Further, in view of the provisions of §10.401(b), the employing agency may not use Form CA-16 to authorize a change of physicians. (c) In determining the use of medical facilities, consideration must be given to their availability, the employee's condition, and the method and means of transportation. Generally, 25 miles from the place of injury, the employing agency, or the employee's home, is a reasonable distance to travel, but other pertinent factors must also be taken into consideration. [49 FR 18979, May 3, 1984] § 10.403 Medical treatment in doubtful cases. Cases of doubtful nature, so far as compensability is concerned, shall be referred by the designated agency official to a United States medical official or hospital, or at the employee's option, to a duly qualified private physician or a duly qualified hospital designated or approved by the Office, or as otherwise provided in this part, using a Form CA-16 for medical services as indicated in 6B of the form. This authorizes the necessary diagnostic studies and emergency treatment pending receipt of advice from the Office. A statement of all pertinent facts relating to the particular case shall also be forwarded immediately to the Office for consideration. If the medical examination or other information received subsequent to the issuance of authorization for treatment discloses that the condition for which treatment was rendered is not due to an injury, the person issuing the authorization shall immediately notify the employee and the physician or hospital that no further treatment shall be rendered at the expense of the Office. In cases of an emer gency or cases involving unusual circumstances, the Office may, in the exercise of its discretion, authorize treatment otherwise than as provided for in this part, or it may approve payment for medical expenses incurred otherwise than as authorized in this section. No authority for examination or for medical or other treatment shall be given by the designated agency official in any case already disallowed by the Office. [49 FR 18979, May 3, 1984] § 10.404 Emergency treatment. In cases of traumatic injury where emergency treatment is necessary, any duly qualified physician may render initial treatment. If oral authorization for such treatment is given by the designated agency official, a Form CA-16 shall be issued within 48 hours thereafter. If further treatment is necessary, authorization therefor shall be be requested as soon as practicable in accordance with §10.402 of this part. It is the duty of the designated agency official to authorize initial medical treatment for acute injuries, exclusive of disease or illness, and to transfer the employee at the employee's option to the care of a local U.S. medical officer or hospital or to a duly qualified private physician or a duly qualified hospital designated or approved by the Office for any subsequent treatment needed. If unable to comply promptly with this requirement, the designated agency official shall communicate with the Office for instructions. [49 FR 18979, May 3, 1984] § 10.405 Medical treatment if symptoms or disability recur. If, after having been discharged from medical treatment, an injured employee again has symptoms or disability under circumstances from which it may reasonably be inferred that such symptoms or disability are the result of an injury previously recognized as compensable by the Office, and the place of employment is the same as at the time of injury, Form CA-16 may be issued at the discretion of the designated agency official. Form CA-16 shall not be used by the designated agency official if more than six months have elapsed since the empoyee last returned to work. In any case in which there may be doubt that the symptoms or disability are the result of the injury, or in which it has been more than six months since the last return to work, the designated agency official shall communicate with the Office and request instructions, stating all the pertinent facts. In all other cases, the employee shall communicate with the Office and request such treatment. [49 FR 18979, May 3, 1984] § 10.406 Authority for dental treatment. All necessary dental treatment, including repairs to natural teeth, false teeth, and other prosthetic dental devices, needed to repair damage or loss caused by an employment related injury shall be obtained at the employee's option from a U.S. Medical Officer or hospital, or from a duly qualified private dentist, a duly qualified physician, or a duly qualified hospital, upon authorization obtained in advance from the Office. [49 FR 18980, May 3, 1984] § 10.407 Medical examinations. (a) An injured employee shall be required to submit to examination by a U.S. Medical Officer or by a qualified private physician approved by the Office as frequently and at such times and places as in the opinion of the Office may be reasonably necessary. The injured employee may have a duly qualified physician, paid by him or her, present at the time of such examination. For any examination required by the Office, an injured employee shall be paid all expenses incident to such examination which, in the opinion of the Office, are necessary and reasonable, including transportation and actual loss of wages incurred in order to submit to the examination authorized by the Office. (b) If the employee refuses to submit himself or herself for or in any way obstructs any examination required by the Office pursuant to paragraph (a) of this section, the employee's right to compensation under the Act shall be suspended until such refusal or obstruction ceases. Compensation other wise paid or payable under the Act and this part for the period of the refusal or obstruction is forfeited and, where already paid, is subject to recovery pursuant to 5 U.S.C. 8129. When notifying an employee of an examination required under paragraph (a) of this section, the Office shall inform the employee of the penalty for refusing or obstructing the examination. [49 FR 18980, May 3, 1984] § 10.408 Medical referee examination. If there should be a disagreement between the physician making the examination on the part of the United States and the injured employee's physician, the Office shall appoint a third physician, qualified in the appropriate speciality, who shall make an examination. The physician appointed shall be one not previously connected with the case. § 10.409 Furnishing of orthopedic and prosthetic appliances, and dental work. When a job-related injury results in the need for an orthopedic or prosthetic appliance, such as an artificial limb, eye, or denture, as recommended by the duly qualified attending physician, written application for authority to purchase such appliance may be made to the Office. The application must include a statement from the attending physician regarding the need for the appliance, a brief description thereof, and the approximate cost. [49 FR 18980, May 3, 1984] § 10.410 Recording and submission of medical reports. (a) Medical officers and private physicians and hospitals shall keep adequate records of all cases treated by them under the Act so as to be able to supply the Office with a history of the employee's accident, the exact description, nature, location, and extent of injury, the X-ray findings or other studies, if X-ray examination or other studies have been made, the nature of the treatment rendered, and the degree of impairment arising from the injury. (b) Form CA-16 provides for the furnishing of the initial medical report. Form CA-20 may also be used for the initial report and for subsequent report. The medical report Form CA-20a attached to Form CA-8 is to be utilized in instances where continued compensation is claimed on such form. These reports shall be forwarded promptly to the Office. In cases of disabling traumatic injuries Form CA-17 shall be used to obtain interim reports concerning the employee's duty status. These reports are necessary to support continuation of pay up to 45 days. (c) Detailed supplementary reports in narrative form shall be made by the physician at approximately monthly intervals in all cases of serious injury or disease, especially injuries of the head and back, and including all cases requiring hospital treatment or prolonged care. The supplementary report shall show the date the employee was first examined or treated, the patient's complaint, the condition found on examination, the diagnosis and medical opinion as to any relationship between the impairment and the injury or employment factors alleged, report as to any other impairments found not due to injury, the treatment given or recommended for the injury alleged, the extent of impairment affecting the employment as a result of the injury, the actual degree of loss of active or passive motion of an injured member, the amount of atrophy or deformity in a member, the the decrease, if any, in strength, the disturbance of sensation, the prognosis for recovery, and all other material findings. If the services of a specialist are required in the examination or treatment of the employee, a report of his findings upon examination, his diagnosis, his opinion as to the relationship between the impairment and the injury and/or conditions of employment, the medical rationale for his opinion, the treatment recommended by him, a statement of the extent of impairment as a result of the injury or employment and the prognosis shall be forwarded to the Office for consideration in conjunction with other reports. The requirement of this section or of any section in this part with respect to the form of medical, dental, hospital or other reports may be waived by the Office. [40 FR 6877, Feb. 14, 1975, as amended at 49 FR 18980, May 3, 1984] § 10.411 Submission of bills for medical services, appliances and supplies; limitation on payment for services. (a)(1) All charges for medical and surgical treatment, appliances or supplies furnished to injured employees, except for treatment and supplies provided by hospitals, pharmacies pharmacies and nursing homes, shall be supported by medical evidence as provided in § 10.410, itemized by the physician or provider on the American Medical Association standard "Health Insurance Claim Form," OWCP 1500a "Instructions for Completing Health Insurance Claim Form," and shall be forwarded promptly to the Office for consideration. The provider of such service shall identify each service performed, using the Health Care Financing Administration Common Procedure Coding System (HCPCS as periodically revised), with brief narrative description or, where no code is applicable, a detailed description of services performed. The provider shall also state each diagnosed condition and furnish the corresponding diagnostic code using the "International Classification of Disease, 9th Edition, Clinical Modification" (ICD-9CM). A separate bill shall be submitted when the employee is discharged from treatment or monthly, if treatment for the work-related condition is necessary for more than 30 days. (2) Charges for medical and surgical treatment provided by hospitals shall be supported by medical evidence as provided in §10.410. Such charges shall be submitted by the provider on the Uniform Bill (UB-82). The provider shall identify each outpatient radiology service (including diagnostic and therapeutic radiology, nuclear medicine and CAT scan procedures, magnetic resonance imaging, and ultrasound and other imaging services), outpatient pathology service (including automated, multichannel tests, panels, urinalysis, chemistry and toxicology, hematology, microbiology, immunology and anatomic pathology), and physical therapy service performed, using HCPCS/CPT codes with a brief narrative description. The charge for each individual service, or the total charge for all identical services should also appear in the UB-82. Other outpatient hospital services for which |