4.0 Footwear benefits list

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4.1 General information

4.1.1 Benefit policies

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

4.1.2 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
  • DPodM — Chiropodists are recognized to prescribe custom-made foot orthotics in Ontario, Saskatchewan, and New Brunswick where their practice is regulated

NIHB recognized providers include:

  • 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)
  • 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

4.1.3 Prior approval requirements

General prior approval requirements can be found in the general policies

To initiate the prior approval process, the NIHB Footwear 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
  • detailed assessment from the provider, including requirements for custom-made shoes and custom-made internal footwear devices
  • additional relevant information the provider, physician, podiatrist (DPM), chiropodist or nurse practitioner 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.)

Custom-made foot orthotics

The following information must be kept on the client's file and provided when requested:

  • diagnosis and client's symptoms
  • biomechanical/medical assessment
  • type of device (for example: accommodative or functional)
  • casting technique (must be one of the following):
    • plaster of Paris slipper cast
    • foam box
    • contact digitizing (Amfit)
    • STS slipper casting
    • full-3D optical scanning (for example, Cast CAD)
  • manufacturing technique and material used
  • name of the laboratory

Note: Casting techniques that do not meet the program requirements may be subject to recovery.

Custom-made shoes

The following information is required for coverage:

  • measurements of the feet
  • photographs of the feet (preferred) and/or templates/drawing/tracing of the contour of the feet
  • prescriber/recommender credentials (for example: nurse practitioner, physician or podiatrist (DPM only))
  • the provider's qualification(s)
  • the client's diagnosis and biomechanical/medical assessment
  • an explanation as to why the client's needs cannot be met by off-the-shelf orthopaedic footwear
  • the casting technique (for example, plaster of Paris slipper cast)
  • manufacturing technique, material used, and design of shoes
  • name of the laboratory

4.1.4 Exclusions

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

  • foot products manufactured only from two-dimensional with extrapolation laser or optical scanning, or computerized gait and pressure analysis systems
  • off-the-shelf, pre-fabricated and heat moldable foot orthotics and internal footwear devices
  • off-the-shelf and orthopaedic/therapeutic footwear (for example: pair of shoes, running shoes, boots, summer sandals, etc.)

4.1.5 Warranties

The manufacturer/provider warranty must include:

  • no charge for necessary adjustments to custom-made foot orthotics for a period of three months after the final fitting, except when there has been a change in the client's medical condition that would prevent a satisfactory fit
  • no charge for repairs to custom-made shoes for a one-year period

4.1.6 Repairs

Repairs that are not covered under the warranty are eligible for coverage when supported by proper documentation.

The following rules apply:

  • prior approval is required
  • request must include detailed cost breakdown of parts, labour time and rates
  • repairs must have a minimum warranty of 90 days

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

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

4.1.7 Replacement requirements

To be eligible for replacement the item must meet ONE of the following conditions:

  • be outside the recommended replacement guideline
  • no longer meets the client's needs due to a change in medical condition
  • no longer functional and outside of warranty where the cost of repair exceeds the cost of a new item

For early replacement, documentation supporting the need must be provided with the prior approval documents.

Custom-made foot orthotics

Replacement after the expiration of the recommended replacement guideline is subject to the same process as the original purchase.

Custom-made shoes

The original prescription/recommendation may be used for a replacement request if ALL of the following conditions are met:

  • the shoes were initially covered by the NIHB program
  • the same provider is requesting coverage
  • replacement is within the recommended replacement guideline

A new prescription/recommendation is required for a replacement when ONE of the following apply:

  • client changes provider
  • client's medical condition changes
  • request is for an early replacement

4.1.8 Services included in the price

The following services must be included in the cost of the item:

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

4.1.9 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.

Maximum price

The NIHB program has established a maximum price for specific items. Maximum price information may be found on the price files located on the Express Script Canada website.

4.2 Custom-made foot orthotics

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400624 Foot orthotic custom-made, pair MD, NP, DPM, DPodM CO(c), CPO(c), TOP, DPM., DPodM, C.Ped(C), C.Ped No 1 every 2 years
99400169 Foot orthotic custom-made, left MD, NP, DPM, DPodM CO(c), CPO(c), TOP, DPM., DPodM, C.Ped(C), C.Ped Yes 1 every 2 years
99400170 Foot orthotic custom-made, right MD, NP, DPM, DPodM CO(c), CPO(c), TOP, DPM., DPodM, C.Ped(C), C.Ped Yes 1 every 2 years

4.3 Custom-made shoes

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400167 Shoes, custom-made MD, NP, DPM CO(c), CPO(c), TOP, DPM., DPodM, C.Ped(C), C.Ped Yes 1 pair per year

4.4 Supplies

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400168 Overshoes winter CO(c), CPO(c), TOP, DPM., DPodM, C.Ped(C), C.Ped Yes 1 every 3 years Prescription not required, however NIHB must have funded a custom shoe for which the overshoe is meant

4.5 Servicing

4.5.1 Modifications

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400171 Modifications to stock footwear MD, NP, DPM CO(c), CPO(c), TOP, DPM., DPodM, C.Ped(C), C.Ped Yes 2 every 2 years Excludes the price of the shoe

4.5.2 Repairs

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400781 Repair for foot orthotics, custom-made CO(c), CPO(c), TOP, DPM., DPodM, C.Ped(C), C.Ped Yes
99400625 Repair for foot orthotics, modification CO(c), CPO(c), TOP, DPM., DPodM, C.Ped(C), C.Ped Yes
99400623 Repair for shoes, custom-made CO(c), CPO(c), TOP, DPM., DPodM, C.Ped(C), C.Ped Yes

4.5.3 Delivery

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401262 Delivery, footwear Yes
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