Medical Supplies and Equipment Benefits List
6.0 Pressure garments and pressure orthotics benefits list
- 6.1 Pressure garments and pressure orthoses
- 6.2 Hypertrophic scar compression garment, custom-made, custom fitted, head
- 6.3 Hypertrophic scar compression garment, custom-made, custom fitted, limb
- 6.4 Hypertrophic scar compression garment, custom-made, custom fitted, trunk
- 6.5 Pressure garments and pressure orthoses accessories
For information on policies regarding the provision of pressure garments and pressure orthotic benefits, please consult the Guide for Medical Supplies and Equipment.
Pressure garments and pressure orthotics benefit 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:
-
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 renewals only) – Registered Nurse (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 - Provider type:
-
GEN-CCGF: enrolled general MS&E or pharmacy provider with staff certified as a compression garment fitter.
Hypertrophic scar pressure garments must be provided by;
GEN–CCGF/CBSGF: enrolled general MS&E or pharmacy provider with staff certified as compression garment fitter or certified burn scar garment fitter. - 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.
6.1 Pressure garments and pressure orthoses
| Item Description | Item Code | Prior Approval | Recommended Replacement Guidelines | Prescriber | Provider |
|---|---|---|---|---|---|
| Compression glove 20-30/30-40mmHg | 99400804 | Yes | 4 pairs per year | MD, NP (OT, PT renewals only) | GEN - CCGF |
| Compression sleeve 20-30, 30-40mmHg | 99400822 | Yes | 4 pairs per year | MD, NP (OT, PT renewals only) | GEN - CCGF |
| Compression sleeve 40mmHg & up | 99400821 | Yes | 4 pairs per year | SURG/SPC | GEN - CCGF |
| Compression stocking, hose, 20-30/30-40 mmHg (Pair) | 99401150 | Yes | 4 pairs per year | MD, NP, RM (OT, PT renewals only) | GEN - CCGF |
| Compression stocking, hose, 40 mmHg+(Pair) | 99401151 | Yes | 4 pairs per year | SURG/SPC | GEN - CCGF |
| Compression stocking, knee, 20-30/30-40 mmHg (Pair) | 99401148 | Yes | 4 pairs per year | MD, NP, RM (OT, PT renewals only) | GEN - CCGF |
| Compression stocking, knee, 40 mmHg+ (Pair) | 99401149 | Yes | 4 pairs per year | SURG/SPC | GEN - CCGF |
| Compression stocking, thigh, 20-30/30-40 mmHg (Pair) | 99401146 | Yes | 4 pairs per year | MD, NP, RM (OT, PT renewals only) | GEN - CCGF |
| Compression stocking, thigh, 40 mmHg+(Pair) | 99401147 | Yes | 4 pairs per year | SURG/SPC | GEN - CCGF |
| Hi-sustained compression bandage 35mmHg, reusable, left | 99400805 | Yes | 6 per year | MD, NP, NSWOC, WOCC(C), (RN renewals only) | GEN - CCGF |
| Hi-sustained compression bandage 35mmHg, reusable, right | 99400841 | Yes | 6 per year | MD, NP, NSWOC, WOCC(C), (RN renewals only) | GEN - CCGF |
| Hi-sustained compression bandage 35mmHg, single use, left | 99400839 | Yes | 24 per year | MD, NP, NSWOC, WOCC(C), (RN renewals only) | GEN - CCGF |
| Hi-sustained compression bandage 35mmHg, single use, right | 99400840 | Yes | 24 per year | MD, NP, NSWOC, WOCC(C), (RN renewals only) | GEN - CCGF |
| Padding single use for reusable hi-sustained compression bandage, left and right | 99400798 | Yes | 48 per year | MD, NP, NSWOC, WOCC(C), (RN renewals only) | GEN - CCGF |
| Stockinette reusable for reusable hi-sustained compression bandage 35mmHg, left and right | 99400842 | Yes | 12 per year | MD, NP, NSWOC, WOCC(C), (RN renewals only) | GEN - CCGF |
6.2 Hypertrophic scar compression garment, custom-made, custom fitted, head
| Item Description | Item Code | Prior Approval | Recommended Replacement Guidelines | Prescriber | Provider |
|---|---|---|---|---|---|
| Hypertrophic scar, chin strap | 99400057 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Hypertrophic scar, chin strap, modified (extended behind the ears) | 99400056 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Hypertrophic scar, ear flap attached to mask or modified chin strap | 99400062 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Hypertrophic scar, eye flap attached to mask | 99400063 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Hypertrophic scar, face mask | 99400054 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Hypertrophic scar, face mask, open face | 99400055 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Hypertrophic scar, head band | 99400058 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Hypertrophic scar, lining variation | 99400064 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Hypertrophic scar, lip covering attached to mask or chin strap | 99400061 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Hypertrophic scar, nose covering in mask | 99400060 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Hypertrophic scar, other garment (provide name of item) | 99400570 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Hypertrophic scar, pocket for padding or splint | 99400059 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Hypertrophic scar, trachea opening | 99400065 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
6.3 Hypertrophic scar compression garment, custom-made, custom fitted, limb
| Item Description | Item Code | Prior Approval | Recommended Replacement Guidelines | Prescriber | Provider |
|---|---|---|---|---|---|
| Arm sleeve and gauntlet with enclosed extended thumb, left | 99400067 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Arm sleeve and gauntlet with enclosed extended thumb, right | 99401098 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Arm sleeve /gauntlet/shoulder flap with enclosed extended thumb, left | 99400068 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Arm sleeve /gauntlet/shoulder flap with enclosed extended thumb, right | 99401099 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Arm sleeve (wrist to axilla), left | 99400074 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Arm sleeve (wrist to axilla), right | 99401100 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Arm sleeve with attached gauntlet, left | 99400075 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Arm sleeve with attached gauntlet, right | 99401101 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Arm sleeve with attached shoulder flap, left | 99400076 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Arm sleeve with attached shoulder flap, right | 99401102 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Arm sleeve with gauntlet and shoulder flap, left | 99400077 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Arm sleeve with gauntlet and shoulder flap, right | 99401103 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Arm stump to axilla, left | 99400078 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Arm stump to axilla, right | 99401104 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Arm stump with shoulder flap, left | 99400079 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Arm stump with shoulder flap, right | 99401105 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Elbow band, left | 99400069 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Elbow band, right | 99401106 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Elbow lining (full), left | 99400082 | Yes | 6 per year | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Elbow lining (full), right | 99401107 | Yes | 6 per year | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Elbow lining (inner aspect), left | 99400081 | Yes | 6 per year | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Elbow lining (inner aspect), right | 99401108 | Yes | 6 per year | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Foot glove, left | 99400571 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Foot glove, right | 99401109 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Half sleeve (elbow to axilla), left | 99400071 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Half sleeve (elbow to axilla), right | 99401110 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Half sleeve (wrist to elbow), left | 99400070 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Half sleeve (wrist to elbow), right | 99401111 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Half sleeve and gauntlet with enclosed extended thumb, left | 99400066 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Half sleeve and gauntlet with enclosed extended thumb, right | 99401112 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Half sleeve with gauntlet metacarpals to elbow, left | 99400072 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Half sleeve with gauntlet metacarpals to elbow, right | 99401113 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Half sleeve with shoulder flap, left | 99400073 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Half sleeve with shoulder flap, right | 99401114 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Hypertrophic scar, anklet, left | 99400567 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Hypertrophic scar, anklet, right | 99401115 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Hypertrophic scar/below knee without foot, left | 99401118 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Hypertrophic scar/below knee without foot, right | 99401119 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Hypertrophic scar/below knee with foot, left | 99401120 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Hypertrophic scar/below knee with foot, right | 99401121 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Hypertrophic scar, chap style, one leg | 99400568 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Hypertrophic scar, chap style, two legs | 99400569 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Lining variation | 99400083 | Yes | 6 per year | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Pocket for padding or splint | 99400085 | Yes | 6 per year | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Reinforced palm on glove or gauntlet, left | 99400084 | Yes | 6 per year | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Reinforced palm on glove or gauntlet, right | 99401116 | Yes | 6 per year | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Shoulder flap, adjustable, left | 99400086 | Yes | 6 per year | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Shoulder flap, adjustable, right | 99401117 | Yes | 6 per year | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Vest with sleeve | 99400572 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Vest without sleeve | 99400573 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Zipper | 99400080 | Yes | 6 per year | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
6.4 Hypertrophic scar compression garment, custom-made, custom fitted, trunk
| Item Description | Item Code | Prior Approval | Recommended Replacement Guidelines | Prescriber | Provider |
|---|---|---|---|---|---|
| Body brief with sleeves | 99400087 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Body brief, sleeveless | 99400088 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Body suit with sleeves and legs (to distal measurement above knees) | 99400089 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
| Body suit, sleeveless with legs (to distal measurement above knees) | 99400090 | Yes | 2 per 3 months | SURG/SPC, (OT, PT renewals only) | GEN - CCGF/CBSGF |
6.5 Pressure garments and pressure orthoses accessories
| Item Description | Item Code | Prior Approval | Recommended Replacement Guidelines | Prescriber | Provider |
|---|---|---|---|---|---|
| Sequential extremity pump, purchase | 99400091 | Yes | Every 5 years | MD, NP | GEN - CCGF |
| Sequential extremity pump, rental | 99400092 | Yes | MD, NP | GEN - CCGF | |
| Sequential Pump accessories, boots | 99400093 | Yes | Every 3 years | MD, NP | GEN - CCGF |
| Sequential Pump accessories, sleeves | 99400094 | Yes | Every 3 years | MD, NP | GEN - CCGF |
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