7.0 Prosthetics benefits list

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7.1 General information

7.1.1 Benefit policies

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

7.1.2 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
  • OPH — Ophthalmologist
  • RN — Registered Nurse

NIHB recognized providers include:

  • CP(c) — Certified Prosthetist
  • 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)
  • BCO — Board Certified Ocularist
  • CMF — Provider must be or must employ a Certified Mastectomy Fitter
  • GEN — Enrolled general medical supplies and equipment or pharmacy provider
  • GEN-CCGF — enrolled general medical supplies and equipment or pharmacy provider with staff certified as a compression garment fitter

7.1.3 Prior approval requirements

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

To initiate the prior approval process, the NIHB Prosthetics 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
  • medical diagnosis
  • a detailed assessment, including the functional potential evaluation and including measures used (for example : predictive or functional measurements, standing balance, current mobility aids required, weight changes, volume changes, etc.) is required to support prior approval requests. The assessment must provide a rationale to support that the requested modular components including prosthetic foot and/or knee are appropriate for client's functional potential or abilities
  • include additional relevant information the provider/physician 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 plans, etc.)

7.1.4 Exclusions

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

  • breast prosthesis:
    • temporary or swim prosthesis
    • silicone implants used in breast reconstruction
    • breast prosthesis for failed breast reconstruction, when the client has not had a mastectomy or lumpectomy
    • breast prosthesis for cosmetic augmentation
    • silicone nipples
  • limb prosthesis:
    • a prosthesis that incudes any external powered or microprocessor components (for example, myoelectric prosthesis)
    • a second prosthesis for the same amputation site
    • early replacement of a prosthetic that has been used beyond manufacturer specifications (for example, for weight lifting or sports)
  • testicular implants
  • wigs and hairpieces

7.1.5 Warranties

Providers must honour the manufacturer's warranty.

In addition:

  • for breast prosthesis, the warranty must guarantee that the prosthesis will remain satisfactory for fit and defects for a minimum of two years
  • for an eye prosthesis, the warranty must guarantee no charge for necessary adjustments for the initial three months following the final fitting, and a one-year warranty against discoloration and separation of materials. An exception can be made when the client's medical condition changes and prevents a satisfactory fit
  • for limb prosthesis, the warranty must guarantee against breakage for six months and no charge for necessary adjustments for three months after the final fitting provided that the individual's size or medical condition has not changed significantly
  • components that are eligible for warranty (for example: feet, knees, vacuum pumps, liners, etc.) will be registered as required by the manufacturer by the provider. Documentation to support registration may be requested if early repair or replacement is requested
  • components (for example: feet, knees, vacuum pumps, liners, etc.) that require repair or replacement that are covered under warranty must be serviced by manufacturer

7.1.6 Repairs

The program will cover minor repairs to prosthetics under a special authorization process. When providers submit a prior approval for a new prosthesis or request a repair to an existing device, a special authorization will be created to allow the provider to directly claim up to the maximum amounts in the price file for subsequent repairs. The special authorization will be effective from the device warranty expiration date to the device frequency limit. Repairs prices include parts and labour.

Prior to performing a repair, the provider must communicate with Express Script Canada to confirm 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:

  • prior approval is required for repairs exceeding the maximum cost or frequency
  • 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.

7.1.7 Replacement requirements

An original prescription may be used for a replacement request when submitted by the same provider if ALL of the following conditions are met:

  • prosthesis was initially covered by the NIHB program
  • prosthesis requested addresses the same medical condition as the original prosthesis
  • the client's functional status remains the same
  • the replacement is within the recommended replacement guideline
  • the prosthesis no longer meets the client's needs due to a change in medical condition

All other requests for replacement require a new prescription. A copy of the prescription and prescriber number must be kept in the clients file at the provider's office with all prosthetic replacements. If a prosthesis is required before the recommended replacement guidelines, prior approval is required and documentation supporting the need for early replacement must be provided.

Simply stating "Stump Atrophy" or "socket ill fitting" or components are worn out or damaged is not a sufficient explanation for replacement. As an example, the submission should also provide details including, but not limited to, the following:

  • the ply of socks that the client wearing
  • the modifications that were completed to address socket fit
  • the measured changes in limb volume due to atrophy or growth
  • a description of a change in medical condition or a minor surgery
  • a description of which parts are worn out and the nature of the wear or damage

7.1.8 Services included in the price

The following services must be included in the cost of the item to be considered for coverage:

  • product or parts ordering and delivery from manufacturer/supplier to provider (including delivery costs, exchange rate)
  • casting or scanning of the body part to design the prosthesis
  • fabrication and aligning components of the prosthesis
  • evaluation, any adjustments to optimize function or fit
  • client education of prosthesis use and final dispensing of prosthesis
  • follow-up visit(s), as per professional association guidelines

7.1.9 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.

7.2 Head and torso

7.2.1 Ocular

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400005 Eye prosthesis, left OPH BCO Yes 1 every 3 years  
99400006 Eye prosthesis, right OPH BCO Yes 1 every 3 years  
99401185 Eye prosthesis, adjustment, left   BCO Yes 1 per year  
99401205 Eye prosthesis, adjustment, right   BCO Yes 1 per year  
99401184 Eye prosthesis, polishing, left   BCO No 1 per year  
99401204 Eye prosthesis, polishing, right   BCO No 1 per year  
99400802 Scleral shell, left OPH BCO Yes 1 every 3 years  
99400803 Scleral shell, right OPH BCO Yes 1 every 3 years  

7.2.2 Breast

Note: Breast prosthesis is to be dispensed within six (6) weeks from the date of the surgical procedure.

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400801 Breast prosthesis, left MD, NP, RN CMF Yes 1 every 2 years  
99400800 Breast prosthesis, right MD, NP, RN CMF Yes 1 every 2 years  
99400003 Breast prosthesis, partial MD, NP, RN CMF Yes 1 every 2 years  

7.3 Upper limb

7.3.1 Fore quarter

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400039 Fore quarter, left MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400040 Fore quarter, right MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  

7.3.2 Shoulder

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400037 Shoulder disarticulation, left MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400038 Shoulder disarticulation, right MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  

7.3.3 Transhumeral

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400035 Transhumeral above elbow, left MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400036 Transhumeral above elbow, right MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  

7.3.4 Elbow

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400033 Elbow disarticulation, left MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400034 Elbow disarticulation, right MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  

7.3.5 Transradial

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400031 Transradial below elbow, left MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400032 Transradial below elbow, right MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  

7.3.6 Wrist

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400029 Wrist disarticulation, left MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400030 Wrist disarticulation, right MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  

7.3.7 Partial hand

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400025 Partial hand, finger remaining, left MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400026 Partial hand, finger remaining, right MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400027 Partial hand, thumb remaining, left MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400028 Partial hand, thumb remaining, right MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  

7.3.8 Finger

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400835 Finger, multiple digits, left MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400836 Finger, multiple digits, right MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400837 Finger, single digit, left MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400838 Finger, single digit, right MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  

7.4 Lower limb

A request for an initial prosthesis requires supporting information, with an explanation beyond simply stating 'first or initial prosthesis'. The following list is an example of the details that could be provided to explain the need for the initial prosthesis:

Requests for a definitive prosthesis will be considered once prosthetic rehabilitation with a preparatory prosthesis has been completed, and there is an indication of progression in rehabilitation. The definitive prosthesis request should include an update on any changes in the client's level of function. Please note that a prosthetic foot, knee joint, and suitable modular components are expected to be reused if a client transitions to a definitive prosthesis.

Specific justification/rationale is required for following situations:

7.4.1 Hip

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400022 Hemipelvectomy or hip disarticulation definitive, left MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400023 Hemipelvectomy or hip disarticulation definitive, right MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400561 Hemipelvectomy or hip disarticulation preparatory, left MD, NP CP(c), CPO(c), TOP Yes    
99400562 Hemipelvectomy or hip disarticulation preparatory, right MD, NP CP(c), CPO(c), TOP Yes    

7.4.2 Transfemoral

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400020 Trans-femoral, above knee, definitive, left MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400021 Trans-femoral, above knee, definitive, right MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400559 Trans-femoral preparatory, left MD, NP CP(c), CPO(c), TOP Yes    
99400560 Trans-femoral preparatory, right MD, NP CP(c), CPO(c), TOP Yes    

7.4.3 Knee

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400018 Knee disarticulation (thru knee), definitive, left MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400019 Knee disarticulation (thru knee), definitive, right MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400557 Knee disarticulation, preparatory, left MD, NP CP(c), CPO(c), TOP Yes    
99400558 Knee disarticulation, preparatory, right MD, NP CP(c), CPO(c), TOP Yes    

7.4.4 Transtibial

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400016 Transtibial, below knee, definitive, left MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400017 Transtibial, below knee, definitive, right MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400555 Transtibial, preparatory, left MD, NP CP(c), CPO(c), TOP Yes    
99400556 Transtibial, preparatory, right MD, NP CP(c), CPO(c), TOP Yes    

7.4.5 Ankle

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400014 Ankle disarticulation, definitive, left MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400015 Ankle disarticulation, definitive, right MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400553 Ankle disarticulation, preparatory, left MD, NP CP(c), CPO(c), TOP Yes    
99400554 Ankle disarticulation, preparatory, right MD, NP CP(c), CPO(c), TOP Yes    

7.4.6 Foot

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400831 Replacement foot for above knee and below knee, left MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400832 Replacement foot for above knee and below knee, right MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400008 Partial foot, shoe insert, definitive, left MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400009 Partial foot, shoe insert, definitive, right MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400010 Partial foot, tibial tube, definitive, left MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400011 Partial foot, tibial tube, definitive, right MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400012 Partial foot, patella tendon, definitive, left MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400013 Partial foot, patella tendon, definitive, right MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  

7.4.7 Socket

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400833 Replacement socket for above knee and below knee, left MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  
99400834 Replacement socket for above knee and below knee, right MD, NP CP(c), CPO(c), TOP Yes 1 every 3 years  

7.5 Supplies

7.5.1 Sleeves

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401189 Suction seal suspension sleeve, left MD, NP CP(c), CPO(c), TOP Yes 6 per year  
99401209 Suction seal suspension sleeve, right MD, NP CP(c), CPO(c), TOP Yes 6 per year  
99401188 Suspension sleeve, left MD, NP CP(c), CPO(c), TOP Yes 10 per year  
99401208 Suspension sleeve, right MD, NP CP(c), CPO(c), TOP Yes 10 per year  

7.5.2 Liners

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401190 Prosthesis liners gel, left MD, NP CP(c), CPO(c), TOP Yes 3 per year  
99401210 Prosthesis liners gel, right MD, NP CP(c), CPO(c), TOP Yes 3 per year  
99401191 Pin system suspension liner, left MD, NP CP(c), CPO(c), TOP Yes 3 per year  
99401211 Pin system suspension liner, right MD, NP CP(c), CPO(c), TOP Yes 3 per year  

7.5.3 Sheaths

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401192 Prosthesis sheaths regular, left MD, NP CP(c), CPO(c), TOP Yes 12 per year  
99401212 Prosthesis sheaths regular, right MD, NP CP(c), CPO(c), TOP Yes 12 per year  
99401193 Prosthesis silo sheath, left MD, NP CP(c), CPO(c), TOP Yes 8 per year  
99401213 Prosthesis silo sheath, right MD, NP CP(c), CPO(c), TOP Yes 8 per year  

7.5.4 Socks

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401197 Filler cotton socks, 1 ply, left MD, NP GEN, CP(c), CPO(c), TOP Yes 12 per year  
99401217 Filler cotton socks, 1 ply, right MD, NP GEN, CP(c), CPO(c), TOP Yes 12 per year  
99401199 Gel stump sock, left MD, NP CP(c), CPO(c), TOP Yes 2 per year  
99401219 Gel stump sock, right MD, NP CP(c), CPO(c), TOP Yes 2 per year  
99401196 Prosthesis stump sock, regular, left MD, NP GEN, CP(c), CPO(c), TOP Yes 12 per year  
99401216 Prosthesis stump sock, regular, right MD, NP GEN, CP(c), CPO(c), TOP Yes 12 per year  

7.5.5 Other

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400002 Mastectomy bra MD, NP, RN CMF Yes 3 per year  
99401195 Prosthesis stump shrinker, left MD, NP CP(c), CPO(c), TOP, GEN-CCGF Yes 4 per year  
99401215 Prosthesis stump shrinker, right MD, NP CP(c), CPO(c), TOP, GEN-CCGF Yes 4 per year  
99401194 Replacement, cosmetic hose, left MD, NP CP(c), CPO(c), TOP Yes 2 per year  
99401214 Replacement, cosmetic hose, right MD, NP CP(c), CPO(c), TOP Yes 2 per year  
99401198 Prosthetic glove, standard, left MD, NP GEN, CP(c), CPO(c), TOP Yes 3 per year  
99401218 Prosthetic glove, standard, right MD, NP GEN, CP(c), CPO(c), TOP Yes 3 per year  

7.6 Servicing

7.6.1 Repairs

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401187 Repair, prosthetic, upper limb, left   CP(c), CPO(c), TOP Yes 1 every 2 years  
99401207 Repair, prosthetic, upper limb, right   CP(c), CPO(c), TOP Yes 1 every 2 years  
99401186 Repair, prosthetic, lower limb, left   CP(c), CPO(c), TOP Yes 1 every year  
99401206 Repair, prosthetic, lower limb, right   CP(c), CPO(c), TOP Yes 1 every year  

7.6.2 Delivery

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401264 Delivery, prosthetics     Yes    
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