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Control Number: <br />401.06.03.087 <br />Version: <br />2.1 <br />Title: <br />Healthcare for Offenders Housed in <br />Non-Idaho Department of Correction <br />Facilities <br />Page Number: <br />5 of 7 <br /> <br />Category 4—Limited Medical Value <br />This category includes medical conditions in which treatment provides little or no <br />medical value, is not likely to provide substantial long-term gain, or is expressly for <br />cosmetic purposes for the offender’s convenience. <br />Examples of conditions considered a category 4 include, but are not limited to: <br />Cosmetic/Acne Treatments <br />• Face cream, lotion, or wash of any kind; <br />• Acne cream, lotion, or wash of any kind; and <br />• Antibiotics for acne. <br />Supplements <br />• Vitamin or herbal supplements of any kind. <br />Nail Fungus <br />Insomnia <br />Miscellaneous <br />• Shoe inserts, <br />• Special footwear, <br />• Special shampoo, and <br />• Chiropractic care. <br />Dental <br />• Prosthetics, <br />• Night or occlusal guards, <br />• Teeth cleaning, and <br />• Root canals. <br />Note: A medical condition in this category does require approval from the health <br />authority prior to providing treatment; however, please be advised that only on rare <br />occasions will conditions in this category receive approval. Submit Appendix A, Medical <br />Request for Payment Authorization, to the Health Services staff. Any item or treatment in <br />this category that is recommended by a healthcare provider may be referred to the <br />health authority for review. The referral must include documentation from the licensed <br />medical provider stating that the item or treatment is medically necessary. <br />Non-category—Dental Conditions or Optometry Care <br />This category includes guidelines and the criteria for approving dental conditions or <br />optometry care that does not fit into any of the four (4) categories listed above.