3.0 Limb and body orthotics equipment and supplies benefits list

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3.1 General information

3.1.1 Benefit policies

General information common to all medical supplies and equipment (MS&E) can be found in the general policies.

3.1.2 Prescriber and provider requirements

Prescriptions or recommendations for coverage must be initiated by the health professionals identified as prescribers or recommenders of the specific item as listed in the tables. Items that are prescribed by prescribers/recommenders not recognized by NIHB for the specific item will lead to denials or reversals of claims.

NIHB recognized prescribers/recommenders include:

  • DPM – Doctor of Podiatric Medicine
  • MD – Physician
  • NP – Nurse Practitioner
  • OT – Occupational Therapist
  • PT – Physiotherapist
  • RN – Registered Nurse
  • RM – Registered Midwife

NIHB recognized providers include:

  • GEN – Enrolled General medical supplies and equipment or Pharmacy Provider
  • CO(c) – Certified Orthotist
  • CPO(c) – Certified Prosthetist Orthotist
  • TOP – "Technicien en orthèses et prothèses" certified by the Canadian Board for the Certification of Prosthetists and Orthotists (CBCPO) or by "l'Ordre des technologues professionnels du Québec (OTPQ)" (Quebec only)
  • CHT – Registered occupational therapists and physiotherapists certified by the Hand Therapy Certification Commission, Inc. (HTCC)
  • DPM – Podiatrist (Doctor of Podiatric Medicine)
  • DPodM – Chiropodist registered with provincial or territorial regulatory bodies
  • C.Ped(C) – Canadian-certified pedorthist
  • C.Ped – Certified Pedorthist or BOC Pedorthist (BOCPD) registered with the Pedorthic Footcare Association (PFA) - Canadian Chapter

3.1.3 Prior Approval Requirements

General prior approval requirements can be found in the general policies.

Off-the-shelf (Class I):
No prior approval is required for off-the-shelf orthoses that are at or below the NIHB unit price and recommended replacement guidelines. Prior approval is required for orthoses above the unit price or when the frequency is exceeded. When prior approval is required the provider must submit their actual acquisition cost and mark-up and include explanation and/or documentation supporting the need for a more advanced device.

Custom-fitted (Class II) and custom-made (Class III):
Prior approval is required for all custom-fitted and custom-made orthotic devices. To initiate the prior approval process, the NIHB Limb and Body Orthotics Prior Approval Form, found on the Express Scripts Canada website, must be completed in full and submitted to the NIHB regional office along with the following supporting documentation:

  • the prescription/recommendation or referral form signed by an NIHB recognized prescriber for the requested benefit
  • a detailed physical and biomechanical assessment from the provider describing the clients need for the requested orthosis as well as how the orthosis will address the clients specific physical and/or mobility needs
  • a detailed description of the orthosis being provided. If Custom Fitted Class II – provide manufacture and model number. If custom-made, provide a description of the orthosis, materials and components incorporated
  • information supporting the request such as:
    • detailed description and explanation for any substantial modifications made to an orthosis that impacts the cost of the orthosis. Description to include need for modification, materials used, clinical and technical time/fee involved
    • detailed cost estimate that lists all components and costs (including labour) for complex, unique, multi-component orthosis such as knee-ankle-foot orthosis
  • additional relevant information the provider, physician, podiatrist, nurse practitioner, occupational therapist, or physiotherapist may have to support the request
  • an explanation of benefits from any third-party coverage available to the client (for example: provincial plan, workers' compensation board, private insurance, education plan, etc.)

3.1.4 Exclusions

In addition to the general exclusion policy listed in the general policies, the following items are excluded from the limb and body orthotics benefit and are not considered for coverage or appeal under the NIHB program:

  • therapy treatment and/or therapy equipment, such as, but not limited to:
    • electrospinal orthosis
    • neurostimulators
    • direct passive movement devices
    • electromagnetic stimulators for osseous growth

3.1.5 Warranties

The warranty must include:

  • breakage guarantee for six months on custom-made orthoses
  • no charge for necessary adjustments to a custom-made orthoses for a period of three months after the final fittingFootnote 1
  • breakage guarantee for two months on customized or pre-fabricated orthoses
  • no charge for necessary adjustments to a customized orthosis/pre-fabricated for a period of 30 days after the final fittingFootnote 1

3.1.6 Repairs

The program will cover minor repairs to limb and body orthotics under the special authorization process. When providers submit a prior approval for a new orthosis, a special authorization will be created to allow the provider to directly claim up to the posted amounts in the price file for any repair required after the device warranty has expired. The special authorization will be effective from the device warranty expiration date to the device frequency limit. Repair prices are to include materials, components and labour. Special authorizations may also be set up for older orthoses when repairs are requested for the first time.

Before doing any repair, providers should confirm with Express Scripts Canada if prior approval is required. Repairs that are not covered under the warranty are eligible for coverage when supported by proper documentation.

The following rules apply:

  • warranty is expired
  • repairs must have a minimum warranty of 90 days
  • request must include detailed cost breakdown of materials, components, labour time and rates
  • prior approval is required for repairs exceeding the recommended frequency or unit price

A description of all repairs with dates, detailed cost breakdown of materials, components, labour time and rates must be kept on file for each client.

Providers may submit a request for prior approval at any time for repairs that may be required over the frequency guideline or posted price.

Note: The NIHB program will not cover the labour cost for repairs that are covered under the warranty.

3.1.7 Replacement requirements

An original prescription may be used for a replacement request when submitted by the same provider if:

  • limb and body orthotic was initially covered by the NIHB program
  • item requested addresses the same medical condition as the original item
  • the client's functional status remains unchanged
  • the replacement is within the recommended replacement guideline

All other requests for replacement require a new prescription. If an item is required before the recommended replacement guidelines, documentation supporting the need for early replacement must be provided.

A copy of the prescription and prescriber number must be kept in the clients file at the provider's office with all orthotic replacements.

3.1.8 Services included in the price

The following services are to be included in the price of the item:

  • initial assessment to determine the type of benefit required
  • product and material/componentry ordering and delivery from manufacturer to provider (including delivery costs, exchange rate)
  • shape/volume capture of the body part for the manufacturing of the device
  • manufacturing/fabricating of the device
  • dispensing of the benefit, which includes the adjustment, fitting
  • follow-up visit(s)

3.1.9 Terminology

Item code

The item code is an 8-digit code that identifies the benefit being requested and is submitted to Express Scripts Canada for billing purposes.

Prior approval

A program coverage confirmation is issued by a FNIHB regional office to a provider to ensure that the client is eligible for specific medical supplies and equipment benefits. The approval is issued primarily for items identified as requiring prior approval before being billed to the program.

Recommended replacement guidelines

The recommended replacement guidelines set a maximum number of each item a client may receive over a given period of time (frequency). Coverage of additional items may be considered on a case-by-case basis. For requests exceeding the recommended replacement guidelines, a prior approval is required.

Unit price

Unit price information may be found on the price files located on the Express Scripts Canada website.

Limb and body orthotic classes are defined as:

Off-the-shelf (class I):
Off-the-shelf or class I orthosis are orthoses that a client can purchase and fit themselves, including items that are typically purchased at a pharmacy. Off-the-shelf orthoses requires minimal assessment and fitting skill. Additionally, any adjustments required to modify or fit the orthosis can be done by hand – for example, bending a metal stay to contour for a better fit to the limb. These products are standard sizes (small, medium, large) or from a sizing chart and may be provided by an NIHB enrolled general medical supplies and equipment or pharmacy provider. Please note, if a manufacturer has a "custom" option for an orthosis that would typically be classified as an off-the-shelf orthosis, such as a neoprene knee sleeve that is custom made to a client's specific measurements, it would still be classified as class I.

Custom-fitted (class II):
A custom-fitted or class II orthosis is more complex than a class I item. Class II items require expertise to either assess or fit the orthosis. For example, the client may have a condition that requires more in depth assessment and/or follow-up such as wound care in diabetic clients. Custom-fit or class II orthosis may require more significant alteration to fit the client, including the use of heat or tools. The item may be selected from a wide range of stock, and be referred to as 'off-the-shelf' however; expertise is required to select the orthosis that would best meet the client's needs. For example, class II off-the-shelf knee orthosis requires very little customizing due to the way the brace is fabricated, however expertise is required to ensure that the brace is suitable for the client and to ensure the forces applied by the orthosis to the knee are appropriate for the condition such as unloading forces in a Osteoarthritis unloading knee brace. Additionally, improperly fitting items could cause more serious health problems such as skin breakdown or aggravating joint/ligament issues. For this reason, NIHB eligible providers of class II braces must be certified Orthotists or certified Prosthetist Orthotists. Certified Hand Therapists certified by the Hand Therapy Certification Commission, Inc. (HTCC) are NIHB eligible providers for upper extremity orthoses only.

Custom-made (class III):
A custom-made or class III orthosis is assessed for, designed, and fabricated based on an individual client measurements using a cast or digital shape and volume capture methods. NIHB eligible providers of these items are certified Orthotists or certified Prosthetist Orthotists. Certified Hand Therapists certified by the Hand Therapy Certification Commission, Inc. (HTCC) are NIHB eligible providers for upper extremity orthoses only.

3.2 Head-torso-spine orthoses

3.2.1 Head and neck

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400151 Cervical, custom-fitted MD, NP, PT CO(c), CPO(c), TOP Yes 1 every 2 years  
99400152 Cervical, custom-made MD, NP CO(c), CPO(c), TOP Yes 1 every 2 years  
99400150 Cervical, off-the-shelf MD, NP, PT GEN No 1 per year  
99400154 Helmet, custom-fitted MD, NP, OT, PT CO(c), CPO(c), TOP Yes 1 every 2 years  
99400155 Helmet, custom-made MD, NP CO(c), CPO(c), TOP Yes 1 every 2 years  
99400153 Helmet, off-the-shelf MD, NP, OT, PT GEN No 1 per year  

3.2.2 Thoracic

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400590 Thoracic, hip-knee-ankle-foot, custom-made MD, NP CO(c), CPO(c), TOP Yes 1 every 2 years Reciprocating gait mechanism
99400164 Thoracolumbarsacral, custom fitted MD, NP CO(c), CPO(c), TOP Yes 1 every 2 years Provide date of fracture and surgery as applicable
99400165 Thoracolumbarsacral, custom-made MD, NP CO(c), CPO(c), TOP Yes 1 every 2 years Provide date of fracture and surgery as applicable
99400163 Thoracolumbarsacral, off-the-shelf MD, NP, PT GEN No 1 per year  

3.2.3 Lumbosacral

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400158 Lumbosacral spinal, custom-fitted MD, NP, PT CO(c), CPO(c), TOP Yes 1 every 2 years  
99400159 Lumbosacral spinal, custom-made MD, NP CO(c), CPO(c), TOP Yes 1 every 2 years  
99400157 Lumbosacral spinal, off-the-shelf MD, NP, PT GEN No 1 per year  

3.2.4 Other head-torso-spine orthoses

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400149 Abdominal support MD, NP, OT, PT, RN GEN No 1 per year  
99400619 Cervical-thoracic-lumbar-sacral, custom-made MD, NP CO(c), CPO(c), TOP Yes 1 every 2 years  
99400618 Cervical-thoracic-lumbar-sacral, custom fitted MD, NP CO(c), CPO(c), TOP Yes 1 every 2 years  
99400156 Hernia truss MD, NP GEN No 1 per year  
99400933 Maternity belt MD, NP, PT, RM, RN GEN No   1 per pregnancy
99400162 Pelvic belt MD, NP, PT GEN No 1 per year  

3.3 Upper extremities

3.3.1 Shoulder

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400603 Shoulder, custom-fitted, left MD, NP, PT CO(C), CPO(C), TOP Yes 1 every 2 years  
99400606 Shoulder, custom-fitted, right MD, NP, PT CO(c), CPO(c), TOP Yes 1 every 2 years  
99400604 Shoulder, custom-made, left MD, NP CO(c), CPO(c), TOP Yes 1 every 2 years  
99400607 Shoulder, custom-made, right MD, NP CO(c), CPO(c), TOP Yes 1 every 2 years  
99400602 Shoulder, off-the-shelf, left MD, NP, PT GEN No 1 per year  
99400605 Shoulder, off-the-shelf, right MD, NP, PT GEN No 1 per year  
99400609 Shoulder-elbow, custom-fitted, left MD, NP, PT CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400612 Shoulder-elbow custom-fitted, right MD, NP, PT CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400610 Shoulder-elbow, custom-made, left MD, NP CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400613 Shoulder-elbow, custom-made, right MD, NP CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400608 Shoulder-elbow, off-the-shelf, left MD, NP, PT GEN No 1 per year  
99400611 Shoulder-elbow, off-the-shelf, right MD, NP, PT GEN No 1 per year  
99400591 Shoulder-elbow-wrist-hand, custom-made, left MD, NP CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400780 Shoulder-elbow-wrist-hand, custom-made, right MD, NP CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  

3.3.2 Elbow

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400125 Elbow, custom-fitted, left MD, NP, PT CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400127 Elbow, custom-fitted, right MD, NP, PT CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400592 Elbow, custom-made, left MD, NP CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400593 Elbow, custom-made, right MD, NP CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400124 Elbow, off-the-shelf, left MD, NP, PT GEN No 1 per year  
99400126 Elbow, off-the-shelf, right MD, NP, PT GEN No 1 per year  

3.3.3 Wrist

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400141 Wrist-hand, custom-fitted, left MD, NP, OT, PT CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400143 Wrist-hand, custom-fitted, right MD, NP, OT, PT CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400614 Wrist-hand, custom-made, left MD, NP CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400615 Wrist-hand, custom-made, right MD, NP CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400140 Wrist-hand, off-the-shelf, left MD, NP, OT, PT GEN No 1 per year  
99400142 Wrist-hand, off-the-shelf, right MD, NP, OT, PT GEN No 1 per year  
99400145 Wrist-hand-finger, custom-fitted, left MD, NP, OT, PT CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400147 Wrist-hand-finger, custom-fitted, right MD, NP, OT, PT CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400616 Wrist-hand-finger, custom-made, left MD, NP CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400617 Wrist-hand-finger, custom-made, right MD, NP CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400144 Wrist-hand-finger, off-the-shelf, left MD, NP, OT, PT GEN No 1 per year  
99400146 Wrist-hand-finger, off-the-shelf, right MD, NP, OT, PT GEN No 1 per year  

3.3.4 Finger

Specify which digits within prior approval request.

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400595 Finger, multiple digits, custom-fitted, left MD, NP, OT, PT CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400599 Finger, multiple digits, custom-fitted, right MD, NP, OT, PT CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400597 Finger, multiple digits, custom-made, left MD, NP CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400601 Finger, multiple digits, custom-made, right MD, NP CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400594 Finger, multiple digits, off-the-shelf, left MD, NP, OT, PT GEN No 1 per year  
99400598 Finger, multiple digits, off-the-shelf, right MD, NP, OT, PT GEN No 1 per year  
99400133 Finger, single digit, custom-fitted, left MD, NP, OT, PT CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400135 Finger, single digit, custom-fitted, right MD, NP, OT, PT CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400596 Finger, single digit, custom-made, left MD, NP CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400600 Finger, single digit, custom-made, right MD, NP CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400132 Finger, single digit, off-the-shelf, left MD, NP, OT, PT GEN No 1 per year  
99400134 Finger, single digit, off-the-shelf, right MD, NP, OT, PT GEN No 1 per year  

3.4 Lower extremities

3.4.1 Hip

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400116 Hip orthosis, custom-fitted, left MD, NP, PT CO(C), CPO(C), TOP Yes 1 every 2 years  
99400118 Hip orthosis, custom-fitted, right MD, NP, PT CO(C), CPO(C), TOP Yes 1 every 2 years  
99400778 Hip orthosis, custom-made, left MD, NP CO(C), CPO(C), TOP Yes 1 every 2 years  
99400779 Hip orthosis, custom-made, right MD, NP CO(C), CPO(C), TOP Yes 1 every 2 years  
99400115 Hip orthosis, off-the-shelf, left MD, NP, PT GEN Yes 1 per year  
99400117 Hip orthosis, off-the-shelf, right MD, NP, PT GEN Yes 1 per year  
99400843 Orthosis for hip dysplasia MD, NP, PT CO(C), CPO(C), TOP Yes 2 per year  

3.4.2 Hip-knee-ankle-foot

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400112 Hip-knee-ankle-foot, custom-fitted, left MD, NP, PT CO(C), CPO(C), TOP Yes 1 every 2 years  
99400114 Hip-knee-ankle-foot, custom-fitted, right MD, NP, PT CO(C), CPO(C), TOP Yes 1 every 2 years  
99400586 Hip-knee-ankle-foot, custom-made, left MD, NP CO(C), CPO(C), TOP Yes 1 every 2 years  
99400587 Hip-knee-ankle-foot, custom-made, right MD, NP CO(C), CPO(C), TOP Yes 1 every 2 years  

3.4.3 Knee

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400100 Knee, custom-fitted, left MD, NP, PT CO(C), CPO(C), TOP Yes 1 every 2 years  
99400102 Knee, custom-fitted, right MD, NP, PT CO(C), CPO(C), TOP Yes 1 every 2 years  
99400582 Knee, custom-made, left MD, NP CO(C), CPO(C), TOP Yes 1 every 2 years  
99400583 Knee, custom-made, right MD, NP CO(C), CPO(C), TOP Yes 1 every 2 years  
99400099 Knee, off-the-shelf, left MD, NP, PT GEN No 1 per year  
99400101 Knee, off-the-shelf, right MD, NP, PT GEN No 1 per year  

3.4.4 Patella

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400588 Patella tendon bearing, knee, custom-made, left MD, NP CO(C), CPO(C), TOP Yes 1 every 2 years  
99400589 Patella tendon bearing, knee, custom-made, right MD, NP CO(C), CPO(C), TOP Yes 1 every 2 years  

3.4.5 Knee-ankle-foot

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400104 Knee-ankle-foot, custom-fitted, left MD, NP, PT CO(C), CPO(C), TOP Yes 1 every 2 years  
99400106 Knee-ankle-foot, custom-fitted, right MD, NP, PT CO(C), CPO(C), TOP Yes 1 every 2 years  
99400584 Knee-ankle-foot, custom-made, left MD, NP CO(C), CPO(C), TOP Yes 1 every 2 years  
99400585 Knee-ankle-foot, custom-made, right MD, NP CO(C), CPO(C), TOP Yes 1 every 2 years  

3.4.6 Ankle

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400575 Ankle, custom-fitted, left MD, NP, PT CO(C), CPO(C), TOP Yes 1 every 2 years  
99400578 Ankle, custom-fitted, right MD, NP, PT CO(C), CPO(C), TOP Yes 1 every 2 years  
99400576 Ankle, custom-made, left MD, NP CO(C), CPO(C), TOP Yes 1 every 2 years  
99400579 Ankle, custom-made, right MD, NP CO(C), CPO(C), TOP Yes 1 every 2 years  
99400574 Ankle, off-the-shelf, left MD, NP, PT GEN No 1 per year  
99400577 Ankle, off-the-shelf, right MD, NP, PT GEN No 1 per year  

3.4.7 Ankle foot

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400096 Ankle-foot, custom-fitted, left MD, NP, PT CO(C), CPO(C), TOP Yes 1 every 2 years  
99400098 Ankle-foot, custom-fitted, right MD, NP, PT CO(C), CPO(C), TOP Yes 1 every 2 years  
99400580 Ankle-foot, custom-made, left MD, NP CO(C), CPO(C), TOP Yes 1 every 2 years  
99400581 Ankle-foot, custom-made, right MD, NP CO(C), CPO(C), TOP Yes 1 every 2 years  
99400095 Ankle-foot, off-the-shelf, left MD, NP, PT GEN No 1 per year  
99400097 Ankle-foot, off-the-shelf, right MD, NP, PT GEN No 1 per year  
99400844 Orthosis for club foot DPM, MD, NP CO(C), CPO(C), TOP, DPM, DPODM, C.PED(C), C.PED Yes 1 per year  

3.4.8 Walking boot

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400808 Foot bed liner, custom-made DPM, MD, NP, PT CO(C), CPO(C), TOP, DPM, DPODM, C.PED(C), C.PED Yes 1 per year To be used with code 99400807 offloading diabetic walking boot
99400807 Offloading diabetic walking boot DPM, MD, NP, PT CO(C), CPO(C), TOP, DPM, DPODM, C.PED(C), C.PED Yes 1 per year Coverage for an offloading diabetic boot is provided for clients with pressure ulcer(s) on the plantar (bottom) of the foot.
99401183 Offloading walking boot DPM, MD, NP, PT GEN Yes 1 per year Coverage is provided for a client that requires an offloading walking boot due to a medical condition for which the walking boot was deemed to be the optimum treatment after considering all factors, including reasonable access to medical treatment.

3.5 Supplies

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400620 Knee brace undersleeve MD, NP, PT GEN Yes 2 per year  
99400621 Liner socks for orthotics MD, NP GEN Yes 6 per year  
99400622 Textile interface garment MD, NP GEN Yes 2 per year  

3.6 Servicing

3.6.1 Repairs

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400945 Repair, lower extremity limb orthosis, left   CO(C), CPO(C), TOP Yes 1 per year  
99400123 Repair, lower extremity limb orthosis, right   CO(C), CPO(C), TOP Yes 1 per year  
99400166 Repair, head-torso-spine orthosis   CO(C), CPO(C), TOP Yes 1 per year  
99400148 Repair, upper extremity limb orthosis, right   CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  
99400946 Repair, upper extremity limb orthosis, left   CO(C), CPO(C), TOP, CHT Yes 1 every 2 years  

3.6.2 Delivery

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401261 Delivery, limb and body orthotics     Yes    
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