4.0 Footwear equipment and supplies benefits list

Effective date: February 26, 2024

The following Medical Supplies and Equipment (MS&E) list contain footwear items and services eligible under the Non-Insured Health Benefits (NIHB) program for eligible First Nations and Inuit. Further you’ll find information on coverage policies, item codes, requirements for prior approval and applicable recommended replacement guidelines.

Table of contents

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 reversal 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:

  • Chiropodist* — Chiropodists are recognized to prescribe custom-made foot orthotics in Ontario, Saskatchewan, and New Brunswick where their practice is regulated
  • MD — Physician
  • NP — Nurse Practitioner
  • Podiatrist* — Podiatrists registered with provincial or territorial regulatory bodies

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:

  • C.Ped — Certified Pedorthist with the title C.Ped, BOCPD registered with the Pedorthic Footcare Association (PFA) Canadian chapter
  • C.Ped(C) — Canadian Certified Pedorthist
  • Chiropodist* — Chiropodist registered with provincial or territorial regulatory bodies
  • CO(c) — Certified Orthotist
  • CPO(c) — Certified Prosthetist Orthotist
  • Podiatrist* — Podiatrists registered with provincial or territorial regulatory bodies
  • 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)

* Chiropodists and podiatrists must include their member class, registration number, and academic designation with their signature.

4.1.3 Prior approval requirements

General prior approval requirements can be found in the general policies

To initiate the prior approval process, the Footwear 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 supporting documentation:

  • the prescription/recommendation or referral form signed by an NIHB-recognized prescriber for the requested benefit and dated before the service date (date the equipment or supplies is provided)
  • current detailed assessment (one year or less) from the provider, including requirements for custom-made shoes and custom-made internal footwear devices
  • additional relevant information the provider, physician, podiatrist, 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.)

4.1.3.1 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 casting
    • contact digitizing (for example, Amfit)
    • STS slipper casting
    • full-3D optical laser scanning (for example, Cast CAD)
    • wax slipper casting
    • raw material direct-to-foot molding
  • manufacturing technique and material used
  • name of the laboratory

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

4.1.3.2 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)
  • the provider's qualifications
  • 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 2-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 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 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 1 year

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

Recommended replacement guidelines indicate the quantity and frequency at which a benefit item will be eligible for coverage. Recommended replacement guidelines are based on a client's customary medical needs and the typical device's lifespan.

Replacement is subject to the same process as the original purchase.

All replacement requests require a new prescription except for custom-made shoes (see section 4.1.7.2 Replacement of custom-made shoes ).

For more general information please see section 1.12 Recommended replacement guidelines.

4.1.7.1 Early replacement requirements

Coverage requests for any early replacement require prior approval, a new prescription as well as documentation supporting the need for early replacement. The client must meet program and equipment-specific eligibility criteria.

Early replacement of items may be considered when one of the following has occurred:

  • there is a substantial change in a client's medical condition (for example, substantial change in growth, etc.) and the item no longer meets the client's needs
  • the item is no longer functioning properly, has deteriorated during typical use and is no longer under warranty (where the cost of repair exceeds the cost of a new item)

The program will not cover the replacement of lost items, stolen items, or items that are damaged due to misuse or negligence.

4.1.7.2 Replacement of custom-made shoes

An original prescription may be used for a replacement request when ALL of the following criteria are met:

  • the request is submitted by the same provider
  • the shoes were initially covered by the NIHB program
  • the item requested addresses the same medical condition as the original item
  • the item is eligible for replacement as per its recommended replacement guidelines

A copy of the prescription and prescriber number must be kept in the client's file at the provider's office with all custom-made shoe replacements.

4.1.8 Services included in the price

The following services must be included in the price 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
  • no charge for the necessary adjustments after the final fitting, except when there has been a change in the client's medical condition that would prevent a satisfactory fit
  • follow-up visits

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 an 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. All claims, including claims accompanied by prior approvals, are subject to claim verification.

Recommended replacement guidelines

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

Price guidance

Price guidance may be found in the price files, located on the Express Scripts Canada NIHB provider and client website. Providers are required to justify their costs and submit for reimbursement according to the NIHB claims submission kit.

4.2 Custom-made foot orthotics

Item code Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400624 Foot orthotic custom-made, pair MD, NP, Podiatrist, Chiropodist CO(c), CPO(c), TOP, Podiatrist, Chiropodist, C.Ped(C), C.Ped No 1 every 2 years Clinician should choose the correct thickness and/or durometer for the client's body weight, anatomy, medical need and expected durability of 2 years
99400169 Foot orthotic custom-made, left MD, NP, Podiatrist, Chiropodist CO(c), CPO(c), TOP, Podiatrist, Chiropodist, C.Ped(C), C.Ped Yes 1 every 2 years  
99400170 Foot orthotic custom-made, right MD, NP, Podiatrist, Chiropodist CO(c), CPO(c), TOP, Podiatrist, Chiropodist, C.Ped(C), C.Ped Yes 1 every 2 years  

4.3 Custom-made shoes

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

4.4 Club foot orthosis

Item code Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400844 Orthosis for club foot Podiatrist, MD, NP CO(c), CPO(c), TOP, Podiatrist, Chiropodist Yes 1 per year Club foot orthosis includes 1 pair of boots and a bar. For the replacement of one of these components (boots and/or bar) for a child during the 1 year, please refer to the appropriate benefit code:
  • 99400845
  • 99400846
  • 99400847
99400847 Club foot orthosis replacement bar – for children Podiatrist, MD, NP CO(c), CPO(c), TOP, Podiatrist, Chiropodist Yes 1 per year Replacement bar for a child’s club foot orthosis (99400844).

For 1 full bar (2 half-bars)
99400845 Club foot orthosis replacement boots - for children under 1 year old Podiatrist, MD, NP CO(c), CPO(c), TOP, Podiatrist, Chiropodist Yes 2 pairs per year Replacement boots for a child under 1 year old who has outgrown the boots of their club foot orthosis (99400844)
99400846 Club foot orthosis replacement boots - for children over 1 year old Podiatrist, MD, NP CO(c), CPO(c), TOP, Podiatrist, Chiropodist Yes 1 pair per year Replacement boots for a child over 1 year old who has outgrown the boots of their club foot orthosis (99400844)

4.5 Supplies

Item code Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400168 Overshoes winter   CO(c), CPO(c), TOP, Podiatrist, Chiropodist, 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

4.6 Servicing

4.6.1 Modifications

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

Applies either to:
  • two modifications to a single shoe every 2 years; or
  • one modification for two individual shoes every 2 years

4.6.2 Repairs

Item code Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400781 Repair for foot orthotics, custom-made   CO(c), CPO(c), TOP, Podiatrist, Chiropodist, C.Ped(C), C.Ped Yes    
99400625 Repair for modification to stock footwear   CO(c), CPO(c), TOP, Podiatrist, Chiropodist, C.Ped(C), C.Ped Yes    
99400623 Repair for shoes, custom-made   CO(c), CPO(c), TOP, Podiatrist, Chiropodist, C.Ped(C), C.Ped Yes    

4.6.3 Delivery

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

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