405 IAC 5-23-3
405 IAC 5-23-3 Covered vision care services
Cite as Ind. Admin. Code tit. 405, r. 5-23-3
Sec. 3. The following services, if medically necessary, may be provided in addition to the initial examination:
(1) Supplemental evaluation.
(2) Multiple pattern fields, including Roberts, Harrington, or Flods.
(3) Central field study.
(4) Peripheral field study.
(5) Tangent screen study.
(6) Color field study.
(7) Binocular ophthalmoscope.
(8) Other supplemental testing.
(9) Visual skills study.
(10) Clinical photography.
(11) Bifocal determination.
(12) Trifocal determination.
(13) Definitive fundus evaluation.
(14) Electrophysiology.
(15) Gonioscopy.
(16) Out-of-office visits.
(17) Neutralization of lens or lenses.
(18) Neutralization of contact lenses.
(19) Extended ophthalmoscopy.
(20) Serial tonometry.
(21) Refractions.
(22) Office visit.
(23) Consultation.
(24) Visual skills testing.
Screening services (excluding EPSDT) for members are not covered by Medicaid, and payment will not be made for such care. All services
provided to recipients in long term care facilities must be documented in the recipient medical record that is maintained by the facility.