8.0 Respiratory equipment and supplies benefits list

Effective date: September 2, 2022

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8.1 General information

8.1.1 Benefit policies

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

8.1.2 Prescriber and provider requirements

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

The following is a list of NIHB recognized prescriber/recommender abbreviations found in this segment of the benefits list. Please refer to the prescriber section of the item tables below to identify the eligible prescriber/recommender of a specific item:

  • INT — Internal Medicine Specialist
  • LPN/RPN – Licensed Practical Nurse/Registered Practical Nurse when within their scope of practice in their province/territory
  • MD — Physician
  • NP — Nurse Practitioner
  • RESP — Respirologist
  • RN — Registered Nurse (renewals only - initial prescription required from MD, NP, NSWOC, WOCC(C))
  • SLP — Speech-Language Pathologist
  • SM — Sleep Medicine Physician

The following is a list of NIHB recognized provider abbreviations found in this segment of the benefits list. Please refer to the provider section of the item tables below to identify the eligible provider of a specific item:

  • GEN — Enrolled general medical supplies and equipment and pharmacy provider
  • RP — Enrolled respiratory provider with appropriate health care staff including regulatory affiliations:
    • RRT — Registered Respiratory Therapist
    • RN — Registered Nurse trained in managing respiratory conditions

8.1.3 Prior approval requirements

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

Prior approval is required for all respiratory equipment and supplies benefits.

To initiate the prior approval process, the Respiratory Prior Approval Form, found on the Express Scripts Canada NIHB provider and client website, must be completed in full and submitted to your NIHB regional office along with the following documentation:

  • required information as described in section 8.2 to 8.5
  • device make, model, and cost
  • additional relevant information the provider, physician, nurse practitioner, other recognized prescriber/recommender 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.)

8.1.4 Exclusions

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

  • respiratory benefits for outings while the client is an in-patient in an acute or long-term hospital setting
  • custom-made masks for ventilation
  • incentive spirometer or volumetric exerciser

8.1.5 Warranties

Provider must honour the manufacturer's warranty.

8.1.6 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 for repairs
  • 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.

8.1.7 Replacement requirements

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

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

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.

8.1.8 Services included in the price

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

  • product ordering and delivery from manufacturer to provider
  • initial product set up and mask fitting
  • instruction on the effective use, care and maintenance of the system
  • all ongoing care including follow-up appointments and calls to monitor effectiveness, support compliance and make necessary adjustments (such as mask re-fit)
  • report generation
  • correspondence with NIHB as part of coverage process
  • correspondence with other health care professionals (physician, sleep lab) as necessary

8.1.9 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 NIHB 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 NIHB provider and client website.

8.2 PAP (positive airway pressure)

Included in the purchase price:

Included in the rental price:

If the applicant requires the use of oxygen with the rental or purchase of a PAP device, please consult 5.0 Oxygen equipment and supplies benefits list for more information on the prior approval requirements for oxygen benefits.

8.2.1 CPAP (continuous positive airway pressure)

The program will accept either:

  • a CPAP (or automatic CPAP (APAP)) rental followed by a purchase, OR
  • an initial request for purchase

8.2.1.1 CPAP rental (up to 3 months)

  • rental may be requested 1 month at a time to:
    • complete PAP titration testing at home
    • demonstrate an improvement in the client's sleep condition
  • an interface and headgear purchase may be covered for the rental period
  • note: the rental fee of the PAP system is to be deducted from the purchase price
Criteria (client must meet A): Required information:
A. diagnosis of obstructive sleep apnea (OSA) with the presence of symptoms.
  • prior approval form including items listed in section 8.1.3 Prior approval requirements
  • clinical information including:
    • age
    • height and weight (Body Mass Index (BMI))
    • Epworth sleepiness scale (ESS)
    • symptoms of sleep-disordered breathing
    • associated risk factors
  • diagnostic sleep study with interpretation by a physician with expertise in sleep medicine
    • accepted sleep studies:
      • level I
      • level III (home sleep study)
      • level IV (overnight oximetry)
    • the apnea-hypopnea index (AHI) must be submitted with the level I and level III sleep study
  • prescription (including pressures)
Note about testing: the NIHB program will consider other testing methods on an exception basis, such as when another diagnostic testing is the accepted testing or standard of care in a given province/territory.

8.2.1.2 CPAP purchase

Purchase may be requested if all the required information is submitted and if there is an improvement in the client's sleep condition (between the diagnostic and treatment sleep study).

Criteria (client must meet A): Required information:
A. diagnosis of obstructive sleep apnea (OSA) with the presence of symptoms.

AND

  • the treatment testing while on the PAP system must demonstrate an improvement** in the applicant's sleep condition

*If prescription is for rental, a new prescription for long term PAP therapy (including pressures) will be required.

**If improvement in the client's condition with the PAP therapy is unclear, the program can request an interpretation from a physician with expertise in sleep medicine and/or summary tracing of the treatment study that confirms requirements.

If the client does not meet all the criteria for purchase, the program may consider rental (please refer to section 8.2.1.1 CPAP rental).

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400175 CPAP, fixed, purchase INT, MD, NP, RESP, SM RP Yes 1 every 5 years
99400174 CPAP, fixed, rental INT, MD, NP, RESP, SM RP Yes up to 3 months
99401084 Auto CPAP (APAP), purchase INT, MD, NP, RESP, SM RP Yes 1 every 5 years
99401083 Auto CPAP (APAP), rental INT, MD, NP, RESP, SM RP Yes up to 3 months

8.2.2 BPAP (bilevel positive airway pressure)

8.2.2.1 BPAP S

Bilevel positive airway pressure with spontaneous breathing (BPAP S) is also referred to as BPAP with no backup rate.

8.2.2.1.1 BPAP S rental (up to 3 months)
Criteria (client must meet ONE): Required information:
  1. diagnosis of OSA and unable to tolerate CPAP pressures
  2. nocturnal saturation of less than 89% despite appropriate CPAP pressures for OSA
  3. nocturnal hypercapnia (PaCO2 greater than 50 mmHg) where the diagnosis of chronic obstructive pulmonary disease (COPD) alone is not the main cause of the hypercapnia despite appropriate CPAP pressures for OSA
  4. AHI is greater than 10 despite appropriate CPAP pressures for OSA

The prescribing physician must have expertise in respiratory medicine.

  • prior approval form including items listed in section 8.1.3 Prior approval requirements
  • prescription (including pressures)
  • diagnostic study:
    • level 1 diagnostic polysomnography with summary tracings and interpretation by a specialist in sleep medicine

    OR

    • level III or IV (oximetry) diagnostic sleep study accepted if the applicant does not have access to a sleep laboratory. Please include summary tracings and interpretation by a specialist in sleep medicine
8.2.2.1.2 BPAP S purchase
Criteria (client must meet ONE): Required information:

AND

  • treatment testing while on the PAP system:
    • level I treatment testing polysomnography with summary tracings and interpretation by a specialist in sleep medicine

    OR

    • level III or IV (oximetry) treatment testing accepted if the applicant does not have access to a sleep laboratory. Please include summary tracings and interpretation by a specialist in sleep medicine

8.2.2.2 BPAP ST

Bilevel positive airway pressure with spontaneous and timed breathing (BPAP ST) is also referred to as BPAP with a backup rate. The device may have additional proprietary ventilation options such as AVAPS.

8.2.2.2.1 BPAP ST rental (up to 3 months)
Criteria (client must meet A or B): Required information:
  1. the applicant has a chronic respiratory failure due to a diagnosis other than COPD, for example: spinal cord injury (SCI)
  2. the applicant has a progressive neuromuscular disease leading to respiratory failure, for example: amyotrophic lateral sclerosis (ALS), muscular dystrophy (MD)

The prescribing physician must have expertise in respiratory medicine.

  • prior approval form including items listed in section 8.1.3 Prior approval requirements
  • physician letter confirming the diagnosis and clinical presentation
  • evidence of diagnostic hypercapnia (for example: arterial blood gas (ABG), capillary blood gas (CBG) or transcutaneous CO2 reading), and nocturnal hypoventilation (oximetry accepted)
  • prescription including pressures and backup rate (BUR)
8.2.2.2.2 BPAP ST purchase
Criteria (client must meet A or B): Required information:

AND

  • evidence of improvement with therapy
Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400211 BPAP S (Standard or Auto), purchase INT, MD, NP, RESP, SM RP Yes 1 every 5 years
99400210 BPAP S (Standard or Auto), rental INT, MD, NP, RESP, SM RP Yes up to 3 months
99400851 BPAP ST (with backup rate), purchase INT, MD, RESP, SM RP Yes 1 every 5 years
99400850 BPAP ST (with backup rate), rental INT, MD, RESP, SM RP Yes up to 3 months

8.3 Secretion clearance

8.3.1 Suction machine

  • rental may be requested 1 month at a time (up to 3 months)
  • if suction machine is still required after 3 months, purchase will be considered

Note: the rental fee of the suction machine is to be deducted from the purchase price.

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400187 Suction machine, purchase INT, MD, NP, RESP GEN Yes 1 every 5 years
99400186 Suction machine, rental INT, MD, NP, RESP GEN Yes

8.4 Supplies

8.4.1 Supplies for PAP

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401152 Chin strap Initial request only - INT, MD, NP, RESP, SM RP Yes 2 per year
99400176 Filters, inlet Initial request only - INT, MD, NP, RESP, SM RP No 14 per year
99401202 Interface with headgear face Initial request only - INT, MD, NP, RESP, SM RP Yes 2 per year
99401220 Interface with headgear nasal Initial request only - INT, MD, NP, RESP, SM RP Yes 2 per year
99401222 Interface headgear nasal pillow Initial request only - INT, MD, NP, RESP, SM RP Yes 2 per year
99400848 Nasal pillows for headgear Initial request only - INT, MD, NP, RESP, SM RP Yes 2 per year
99401221 Tubing CPAP/BPAP standard Initial request only - INT, MD, NP, RESP, SM RP Yes 2 per year

8.4.2 Supplies for tracheostomy

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400626 Distilled water, 4l container MD, NP, SLP, RN, (LPN/RPN - renewals only) GEN No 55 per year For tracheostomy care only
99401232 Heat & moisture exchanger (HME), standard MD, NP, SLP GEN No 1 per day
99401233 Heat & moisture exchanger (HME), specialized MD, NP, SLP GEN No 1 per day
99401234 Heat & moisture exchanger (HME), housing/baseplate, standard MD, NP, SLP GEN No 1 per day
99401235 Heat & moisture exchanger (HME), housing/baseplate, specialized MD, NP, SLP GEN No 1 per day
99400197 Hydrogen peroxide MD, NP, RN, SLP GEN No 72 per year
99400198 Pipe cleaners MD, NP, RN, SLP GEN No 240 per year
99400193 Speaking valves MD, NP, SLP GEN Yes 4 per year
99400201 Tracheostomy brush MD, NP, SLP, RN, (LPN/RPN - renewals only) GEN No 6 per year
99400200 Tracheostomy drain sponge MD, NP, RN, SLP GEN No 800 per year
99400627 Tracheostomy mask MD, NP, RN, (LPN/RPN - renewals only) GEN No 24 per year
99400178 Tracheostomy ties, roll MD, NP, SLP, RN, (LPN/RPN - renewals only) GEN No 2 per year
99400194 Tracheostomy tube MD, NP, SLP GEN Yes 24 per year Includes the outer cannula with flange (neck plate), the reusable inner cannula, and the obturator

8.4.3 Supplies for secretion clearance

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400185 Suction, catheter, disposable MD, NP, (RN, LPN/RPN - renewals only) GEN Yes 2000 per year
99400189 Suction, Yankauer, tonsil MD, NP, (RN, LPN/RPN - renewals only) GEN No 26 per year
99400188 Tubing and collection bottle MD, NP, (RN, LPN/RPN - renewals only) GEN No 26 per year

8.5 Servicing

8.5.1 Repairs

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400195 Repair, respiratory equipment GEN Yes

8.5.2 Delivery

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401265 Delivery, respiratory Yes Delivery of equipment to the client
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