Medical Supplies and Equipment Benefit Lists

4.0 Custom-made shoes and custom-made foot orthotics benefits list

For information on policies regarding the provision of custom-made shoes and custom-made foot orthotics benefits, please consult the Guide for Medical Supplies and Equipment.

Custom-made shoes and custom-made foot orthotics benefits list

List terminology

Item description:
Items are listed within general and specific categories (for example: Audiology), in alphabetical order by category and item.
Item code:
The 8-digit code that must be submitted to ESI Canada for billing purposes.
Prior approval:
Identifies by general category, or by item within the category, whether prior approval must be obtained by the provider before dispensing the item.
Recommended replacement guidelines:
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.
Prescriber type:

D.P.M – Podiatrist (Doctor of Podiatric Medicine)
MD – Physician
NP – Nurse Practitioner

Provider type: (must be provided according to their provincial/territorial scope of practice)

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)
D.P.M. – 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

Maximum price:

The NIHB Program has established a maximum price coverage for certain items. The maximum national prices are shown in the tables below (please note that in some cases a price grid has been established for the provinces and one for the territories). The maximum prices for each province and territory are listed on the Express Script Canada website and can be viewed by clicking on the appropriate link in the benefit listings.

When a maximum price is established by the Program, the provider cannot claim a markup on the reimbursement request since it is included in the price.

4.1 Custom-made shoes

Custom-made footwear
Item Description Item Code Prior Approval Recommended Replacement Guidelines Prescriber Provider
Custom-made shoes 99400167 Yes 1 per year MD, NP, D.P.M CO(c), CPO(c), TOP, D.P.M., DPodM, C.Ped(c), C.Ped
Repairs to custom made shoes 99400623 Yes     CO(c), CPO(c), TOP, D.P.M., DPodM, C.Ped(c), C.Ped
Winter overshoes (only for clients with custom footwear) 99400168 Yes Every 3 years MD, NP, D.P.M CO(c), CPO(c), TOP, D.P.M., DPodM, C.Ped(c), C.Ped

4.2 Custom-made foot orthotics

Custom-made foot orthotics
Item Description Item Code Prior Approval Recommended Replacement Guidelines Maximum Price Prescriber Provider
Custom-made foot orthotics, left 99400169 Yes 1 every 2 years   MD, NP, D.P.M CO(c), CPO(c), TOP, D.P.M., DPodM, C.Ped(c), C.Ped
Custom-made foot orthotics, right 99400170 Yes 1 every 2 years   MD, NP, D.P.M CO(c), CPO(c), TOP, D.P.M., DPodM, C.Ped(c), C.Ped
Custom-made foot orthotics, pair 99400624 No 1 every 2 years $474.26 MD, NP, D.P.M CO(c), CPO(c), TOP, D.P.M., DPodM, C.Ped(c), C.Ped
Custom-made foot orthotics, repairs 99400781 Yes       CO(c), CPO(c), TOP, D.P.M., DPodM, C.Ped(c), C.Ped

4.3 Modifications to stock footwear

Modifications to stock footwear
Item Description Item Code Prior Approval Recommended Replacement Guidelines Prescriber Provider
Modifications to stock footwear (this does not include the price of the shoe) 99400171 Yes 2 per 2 years MD, NP, D.P.M CO(c), CPO(c), TOP, D.P.M., DPodM, C.Ped(c), C.Ped
Repairs to footwear modifications 99400625 Yes     CO(c), CPO(c), TOP, D.P.M., DPodM, C.Ped(c), C.Ped
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