Medical Supplies and Equipment Benefits List

6.0 Pressure garments and pressure orthotics benefits list

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

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

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

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

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

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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