6.0 Pressure devices benefits list

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6.1 General information

6.1.1 Benefit policies

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

6.1.2 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:

  • MD — Physician
  • NP — Nurse Practitioner
  • NSWOC — Nurse Specialized in Wound, Ostomy and Continence
  • OT — Occupational Therapist associated with a burn unit/clinic and/or a plastic surgery unit/clinic (renewals only)
  • PT — Physiotherapist with a burn unit/clinic and/or a plastic surgery unit/clinic (renewals only)
  • RM — Registered Midwife
  • RN — Registered Nurse (renewals only — initial prescription required from MD, NP, NSWOC, WOCC(C))
  • SURG/SPC — Surgeon (including general, plastic, orthopedic, vascular) or an Internist, a Pediatrician, a Physiatrist or an Oncologist
  • WOCC(C) — Wound, Ostomy and Continence Certified (C)anada

NIHB recognized providers include:

Compression garments:

  • GEN-CCGF: enrolled general medical supplies and equipment or pharmacy provider with staff certified as a compression garment fitter

Hypertrophic scar pressure garments:

  • GEN–CCGF/CBSGF: enrolled general medical supplies and equipment or pharmacy provider with staff certified as compression garment fitter or certified burn scar garment fitter

6.1.3 Prior approval requirements

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

To initiate the prior approval process, the NIHB Pressure Devices 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 or recommendation or referral form listing the required compression signed by an NIHB recognized prescriber for the requested benefit
  • additional relevant information the provider/physician, nurse practitioner or registered midwife may have to support the request
  • qualifications and the title of the fitter
  • whether the item is custom-fitted or custom-made
  • exact client measures are required for custom made items
  • name of the manufacturer and model of the item
  • 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.)

6.1.4 Exclusions

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

  • compression garments for short-term treatment (for example, pre- and post-surgery)
  • pre- and post-medical treatment
  • post-traumatic edema

6.1.5 Warranties

Providers must honour the manufacturer's warranty.

6.1.6 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.

6.1.7 Replacement requirements

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

  • be outside the recommended replacement guideline
  • the item no longer meets the client's needs due to a change in medical condition
  • not working, outside of warranty and the cost of repair exceeds the cost of a new item

All 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.

6.1.8 Services included in the price

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

  • initial assessment to determine type of benefit required
  • measuring body part to manufacture the device in precise measurement
  • manufacturing the device
  • dispensing the benefit, including adjustment and fitting
  • follow-up visits, as per professional/industry standards
  • product and parts ordering and delivery from manufacturer to provider (including delivery costs, exchange rate)

6.1.9 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.

6.2 Compression garments

6.2.1 Sleeve

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400822 Sleeve compression, 20-30/30-40 mmHg MD, NP, (OT, PT — renewals only) GEN — CCGF Yes 4 per year
99400821 Sleeve compression, 40 mmHg+ SURG/SPC GEN — CCGF Yes 4 per year

6.2.2 Glove

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400804 Glove compression, 20-30/30-40 mmHg MD, NP, (OT, PT — renewals only) GEN — CCGF Yes 4 per year

6.2.3 Stocking

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401150 Stocking, hose, 20-30/30-40 mmHg, pair MD, NP, RM, (OT, PT — renewals only) GEN — CCGF Yes 4 per year
99401151 Stocking, hose, 40 mmHg+, pair SURG/SPC GEN — CCGF Yes 4 per year
99401148 Stocking, knee, 20-30/30-40 mmHg, pair MD, NP, RM, (OT, PT — renewals only) GEN — CCGF Yes 4 per year
99401149 Stocking, knee, 40 mmHg+, pair SURG/SPC GEN — CCGF Yes 4 per year
99401146 Stocking, thigh, 20-30/30-40 mmHg, pair MD, NP, RM, (OT, PT — renewals only) GEN — CCGF Yes 4 per year
99401147 Stocking, thigh, 40 mmHg+, pair SURG/SPC GEN — CCGF Yes 4 per year

6.2.4 Bandages

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400839 Compression bandage, 35 mmHg, single use, left MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN — CCGF Yes 24 per year
99400840 Compression bandage, 35 mmHg, single use, right MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN — CCGF Yes 24 per year
99400805 Compression bandage, 35 mmHg, reusable, left MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN — CCGF Yes 6 per year
99400841 Compression bandage, 35 mmHg, reusable, right MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN — CCGF Yes 6 per year
99400842 Stockinette, reusable, for reusable compression bandage, 35 mmHg, left and right MD, NP, NSWOC, WOCC(C), (RN renewals only) GEN — CCGF Yes 12 per year
99400798 Padding, single use, for reusable compression bandage, left and right MD, NP, NSWOC, WOCC(C) (RN renewals only) GEN — CCGF Yes 48 per year

6.3 Burn garment for hypertrophic scar

Indicate site and percentage of the body affected

6.3.1 Head

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400056 Chin-ears strap SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months Extended behind the ears
99400058 Chin-head band SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400057 Chin strap SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400062 Ear flap attached to mask or modified chin strap SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400063 Eye flap attached to mask SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400054 Face mask SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400061 Face mask, lipcover attached SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400060 Face mask, nose cover mask SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400055 Face mask, open SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400064 Lining variation SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400059 Pocket pad splint SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400065 Trachea opening SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months

6.3.2 Arm

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400074 Arm sleeve, wrist to axilla, left SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99401100 Arm sleeve, wrist to axilla, right SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400067 Arm sleeve gauntlet with thumb, left SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99401098 Arm sleeve gauntlet with thumb, right SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400075 Arm sleeve with attached gauntlet, left SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99401101 Arm sleeve with attached gauntlet, right SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400076 Arm sleeve with attached shoulder flap, left SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99401102 Arm sleeve with attached shoulder flap, right SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400077 Arm sleeve with gauntlet shoulder flap, left SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99401103 Arm sleeve with gauntlet shoulder flap, right SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400068 Arm sleeve with gauntlet shoulder flap thumb, left SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99401099 Arm sleeve with gauntlet shoulder flap thumb, right SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400078 Arm stump to axilla, left SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99401104 Arm stump to axilla, right SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400079 Arm stump with shoulder flap, left SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99401105 Arm stump with shoulder flap, right SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months

6.3.3 Elbow

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400069 Elbow band, left SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99401106 Elbow band, right SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400082 Elbow lining (full), left SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 6 per year
99401107 Elbow lining (full), right SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 6 per year
99400081 Elbow lining (inner aspect), left SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 6 per year
99401108 Elbow lining (inner aspect), right SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 6 per year

6.3.4 Half sleeve

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400071 Half sleeve (elbow to axilla), left SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99401110 Half sleeve (elbow to axilla), right SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400070 Half sleeve (wrist to elbow), left SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99401111 Half sleeve (wrist to elbow), right SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400066 Half sleeve gauntlet with thumb, left SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99401112 Half sleeve gauntlet with thumb, right SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400072 Half sleeve with gauntlet (metacarpal-elbow), left SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99401113 Half sleeve with gauntlet (metacarpal-elbow), right SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400073 Half sleeve with shoulder flap, left SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99401114 Half sleeve with shoulder flap, right SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months

6.3.5 Body

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400087 Body brief with sleeves SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400088 Body brief sleeveless SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400089 Body suit with sleeves and legs SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400090 Body suit sleeveless with legs SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months

6.3.6 Chap

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400568 Hypertrophic scar, chap, 1 leg SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400569 Hypertrophic scar, chap, 2 legs SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months

6.3.7 Knee-foot

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401120 Hypertrophic scar, knee with foot, left SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99401121 Hypertrophic scar, knee with foot, right SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99401118 Hypertrophic scar, knee without foot, left SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99401119 Hypertrophic scar, knee without foot, right SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months

6.3.8 Anklet

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400567 Hypertrophic scar, anklet, left SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99401115 Hypertrophic scar, anklet, right SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months

6.3.9 Foot

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400571 Foot glove, left SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99401109 Foot glove, right SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months

6.3.10 Other

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400570 Hypertrophy scar other garment SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400083 Lining variation SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 6 per year
99400085 Pocket for padding or splint SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 6 per year
99400084 Reinforced palm-glove gauntlet, left SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 6 per year
99401116 Reinforced palm-glove gauntlet, right SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 6 per year
99400086 Shoulder flap, adjustable, left SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 6 per year
99401117 Shoulder flap, adjustable, right SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 6 per year
99400572 Vest with sleeve SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400573 Vest without sleeve SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 2 every 3 months
99400080 Zipper SURG/SPC, (OT, PT — renewals only) GEN — CCGF/CBSGF Yes 6 per year

6.4 Compression devices

6.4.1 Sequential pump

Indicate site and cause of lymphedema on prior approval request.

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400093 Sequential pump extremity boots MD, NP GEN — CCGF Yes 1 every 3 years
99400094 Sequential pump extremity, sleeves MD, NP GEN — CCGF Yes 1 every 3 years
99400091 Sequential pump extremity, purchase MD, NP GEN — CCGF Yes 1 every 5 years
99400092 Sequential pump extremity, rental MD, NP GEN — CCGF Yes A sequential extremity pump can be rented on a trial basis for one month before final purchase however; the rental fee will be applied to the purchase price

6.5 Servicing

6.5.1 Delivery

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401263 Delivery, pressure devices GEN Yes
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