Medical Supplies and Equipment Benefit Lists

3.0 Limb and body orthotics benefits list

For information on policies regarding the provision of limb and body orthotics benefits, please consult the Guide for Medical Supplies and Equipment.

Limb and body 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.
Off-the-shelf (Class I) :
An orthosis that a client can purchase and fit themselves, including items that are typically purchased at a pharmacy. The device requires very minimal assessment and alterations – such as just bending a metal stay to contour better to the limb and could be done by hand. These products would be sized small, medium, large or from a sizing chart. These items can be provided by a general MSE provider.
Custom-fitted (Class II):
This is an orthosis that is more complex than a class 1 item. It requires expertise either for fit or assessment. The item may require more significant alteration to fit the client, including the use of heat or tools.  The item may be selected from a wide range of stock, and be referred to as ‘off-the-shelf’; however, expertise is required to select the orthosis that would best meet the client’s needs.  For example, Class II off the shelf knee orthosis requires very little customizing due to the way the braces are fabricated, however expertise is required to ensure that the brace is suitable for the client. An improperly fit item could have more serious consequences, including skin breakdown or aggravating joint/ligament issues. For these reasons, NIHB eligible providers of class 2 braces are certified Orthotists or certified Prosthetist Orthotists and for upper extremity only, Certified Hand Therapists.
Custom-made (Class III):
An orthosis, regardless of where it is manufactured, that is made based on individual client measurements, cast or, or digital measurement. NIHB eligible providers of these items are certified Orthotists or certified Prosthetist Orthotists and for upper extremity only, Certified Hand Therapists.
Prescriber type:
DPM – Doctor of Podiatric Medicine
MD – Physician
NP – Nurse Practitioner
OT – Occupational Therapist
PT – Physiotherapist
RN – Registered Nurse
Provider type:
GEN – Enrolled General MS&E or Pharmacy Provider
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)
CHT – Registered occupational therapists and physiotherapists certified by the Hand Therapy Certification Commission, Inc. (HTCC)
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.

Please note: 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.

3.1 Limb orthoses - lower extremity

Limb orthoses - lower extremity – custom-fitted
Item Description Item Code Prior Approval Recommended Replacement Guidelines Maximum Price Prescriber Provider
Ankle, custom-fitted, left 99400575 Yes 1 every 2 years   MD, NP, PT CO(c), CPO(c), TOP
Ankle, custom-fitted, right 99400578 Yes 1 every 2 years   MD, NP, PT CO(c), CPO(c), TOP
Ankle foot, custom-fitted, left 99400096 Yes 1 every 2 years   MD, NP, PT CO(c), CPO(c), TOP
Ankle foot, custom-fitted, right 99400098 Yes 1 every 2 years   MD, NP, PT CO(c), CPO(c), TOP
Foot bed liner custom (for 99400807) 99400808 Yes 1 per year   MD, NP, PT, DPM CO(c), CPO(c), TOP, D.P.M., DPodM, C.Ped(c), C.Ped
Knee custom-fitted, left 99400100 Yes 1 every 2 years   MD, NP, PT CO(c), CPO(c), TOP
Knee, custom-fitted, right 99400102 Yes 1 every 2 years   MD, NP, PT CO(c), CPO(c), TOP
Knee ankle foot, custom-fitted, left 99400104 Yes 1 every 2 years   MD, NP, PT CO(c), CPO(c), TOP
Knee ankle foot, custom-fitted, right 99400106 Yes 1 every 2 years   MD, NP, PT CO(c), CPO(c), TOP
Hip knee ankle foot, custom-fitted, left 99400112 Yes 1 every 2 years   MD, NP, PT CO(c), CPO(c), TOP
Hip knee ankle foot, custom-fitted, right 99400114 Yes 1 every 2 years   MD, NP, PT CO(c), CPO(c), TOP
Hip orthosis, custom-fitted, left 99400116 Yes 1 every 2 years   MD, NP, PT CO(c), CPO(c), TOP
Hip orthosis, custom-fitted, right 99400118 Yes 1 every 2 years   MD, NP, PT CO(c), CPO(c), TOP
Orthosis for hip dysplasia 99400843 Yes 2 per year   MD, NP, PT CO(c), CPO(c), TOP
Orthosis for club foot 99400844 Yes 1 per year   MD, NP, D.P.M. CO(c), CPO(c), TOP, D.P.M., DPodM, C.Ped(c), C.Ped
Offloading diabetic walking boot 99400807 Yes 1 per year   MD, NP, PT, D.P.M. CO(c), CPO(c), TOP, D.P.M., DPodM, C.Ped(c), C.Ped
Offloading walking boot 99401183 Yes 1 per year   MD, NP, PT, D.P.M. GEN
Limb orthoses - lower extremity – custom-made
Item Description Item Code Prior Approval Recommended Replacement Guidelines Maximum Price Prescriber Provider
Ankle custom-made, left 99400576 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP
Ankle, custom-made, right 99400579 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP
Ankle foot custom-made, left 99400580 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP
Ankle foot custom-made, right 99400581 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP
Knee custom-made, left 99400582 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP
Knee custom-made, right 99400583 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP
Knee ankle foot custom-made, left 99400584 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP
Knee ankle foot custom-made, right 99400585 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP
Hip knee ankle foot custom-made, left 99400586 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP
Hip knee ankle foot custom-made, right 99400587 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP
Hip orthosis custom-made, left 99400778 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP
Hip orthosis custom-made, right 99400779 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP
Patella tendon bearing knee custom-made, left 99400588 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP
Patella tendon bearing knee custom-made, right 99400589 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP
Thoracic hip knee ankle foot (reciprocating gait mechanism) custom-made 99400590 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP
Repair - Lower extremity limb orthosis, left 99400945 Yes 1 per year Footnote * $150.00   CO(c), CPO(c), TOP
Repair - Lower extremity limb orthosis, right 99400123 Yes 1 per year Footnote * $150.00   CO(c), CPO(c), TOP
Limb orthoses - lower extremity – off-the-self
Item Description Item Code Prior Approval Recommended Replacement Guidelines Maximum Price Prescriber Provider
Ankle, off-the-shelf, left 99400574 No 1 per year $63.00 MD, NP, PT GEN
Ankle, off-the-shelf, right 99400577 No 1 per year $63.00 MD, NP, PT GEN
Ankle foot, off-the-shelf, left 99400095 No 1 per year $68.00 MD, NP, PT GEN
Ankle foot, off-the-shelf, right 99400097 No 1 per year $68.00 MD, NP, PT GEN
Knee, off-the-shelf, left 99400099 No 1 per year $69.00 MD, NP, PT GEN
Knee, off-the-shelf, right 99400101 No 1 per year $69.00 MD, NP, PT GEN
Hip orthosis, off-the-shelf, left 99400115 Yes 1 per year   MD, NP, PT GEN
Hip orthosis, off-the-shelf, right 99400117 Yes 1 per year   MD, NP, PT GEN

3.2 Limb orthoses - upper extremity

Limb orthoses - upper extremity – custom-fitted
Item Description Item Code Prior Approval Recommended Replacement Guidelines Maximum Price Prescriber Provider
Elbow, custom-fitted, left 99400125 Yes 1 every 2 years   MD, NP, PT CO(c), CPO(c), TOP, CHT
Elbow, custom-fitted, right 99400127 Yes 1 every 2 years   MD, NP, PT CO(c), CPO(c), TOP, CHT
Finger, single digit, custom-fitted, left (specify digit) 99400133 Yes 1 every 2 years   MD, NP, OT, PT CO(c), CPO(c), TOP, CHT
Finger, multiple digits, custom-fitted, left (specify digits) 99400595 Yes 1 every 2 years   MD, NP, OT, PT CO(c), CPO(c), TOP, CHT
Finger, single digit, custom-fitted, right (specify digit) 99400135 Yes 1 every 2 years   MD, NP, OT, PT CO(c), CPO(c), TOP, CHT
Finger, multiple digits, custom-fitted, right (specify digits) 99400599 Yes 1 every 2 years   MD, NP, OT, PT CO(c), CPO(c), TOP, CHT
Shoulder, custom-fitted, left 99400603 Yes 1 every 2 years   MD, NP, PT CO(c), CPO(c), TOP
Shoulder, custom-fitted, right 99400606 Yes 1 every 2 years   MD, NP, PT CO(c), CPO(c), TOP
Shoulder elbow, custom-fitted, left 99400609 Yes 1 every 2 years   MD, NP, PT CO(c), CPO(c), TOP, CHT
Shoulder elbow, custom-fitted, right 99400612 Yes 1 every 2 years   MD, NP, PT CO(c), CPO(c), TOP, CHT
Wrist hand, custom-fitted, left 99400141 Yes 1 every 2 years   MD, NP, OT, PT CO(c), CPO(c), TOP, CHT
Wrist hand, custom-fitted, right 99400143 Yes 1 every 2 years   MD, NP, OT, PT CO(c), CPO(c), TOP, CHT
Wrist hand finger, custom-fitted, left 99400145 Yes 1 every 2 years   MD, NP, OT, PT CO(c), CPO(c), TOP, CHT
Wrist hand finger, custom-fitted, right 99400147 Yes 1 every 2 years   MD, NP, OT, PT CO(c), CPO(c), TOP, CHT
Limb orthoses - upper extremity – custom-made
Item Description Item Code Prior Approval Recommended Replacement Guidelines Maximum Price Prescriber Provider
Elbow, custom-made, left 99400592 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP, CHT
Elbow, custom-made, right 99400593 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP, CHT
Finger, single digit, custom-made, left 99400596 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP, CHT
Finger, multiple digits, custom-made, left 99400597 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP, CHT
Finger, single digit, custom-made, right 99400600 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP, CHT
Finger, multiple digits custom-made, right 99400601 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP, CHT
Shoulder, custom-made, left 99400604 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP
Shoulder, custom-made, right 99400607 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP
Shoulder elbow, custom-made, left 99400610 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP, CHT
Shoulder elbow, custom-made, right 99400613 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP, CHT
Shoulder elbow wrist hand, custom-made, left 99400591 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP, CHT
Shoulder elbow wrist, hand, custom-made, right 99400780 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP, CHT
Wrist hand, custom-made, left 99400614 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP, CHT
Wrist hand, custom-made, right 99400615 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP, CHT
Wrist hand finger, custom-made, left 99400616 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP, CHT
Wrist hand finger, custom-made, right 99400617 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP, CHT
Repairs - upper extremity limb orthosis, left 99400946 Yes 1 per 2 years Footnote * $200.00   CO(c), CPO(c), TOP, CHT
Repairs - upper extremity limb orthosis, right 99400148 Yes 1 per 2 years Footnote * $200.00   CO(c), CPO(c), TOP, CHT
Limb orthoses - upper extremity – off-the-shelf
Item Description Item Code Prior Approval Recommended Replacement Guidelines Maximum Price Prescriber Provider
Elbow, off-the-shelf, left 99400124 No 1 per year $32.00 MD, NP, PT GEN
Elbow, off-the-shelf, right 99400126 No 1 per year $32.00 MD, NP, PT GEN
Finger, single digit, off-the-shelf, left (specify digit) 99400132 No 1 per year $33.50 MD, NP, OT, PT GEN
Finger, multiple digits, off-the-shelf, left (specify digits) 99400594 No 1 per year $36.00 MD, NP, OT, PT GEN
Finger, single digit, off-the-shelf, right (specify digit) 99400134 No 1 per year $33.50 MD, NP, OT, PT GEN
Finger, multiple digits, off-the-shelf, right (specify digits) 99400598 No 1 per year $36.00 MD, NP, OT, PT GEN
Shoulder, off-the-shelf, left 99400602 No 1 per year $37.00 MD, NP, PT GEN
Shoulder, off-the-shelf, right 99400605 No 1 per year $37.00 MD, NP, PT GEN
Shoulder elbow, off-the-shelf, left 99400608 No 1 per year $25.50 MD, NP, PT GEN
Shoulder elbow, off-the-shelf, right 99400611 No 1 per year $25.50 MD, NP, PT GEN
Wrist hand, off-the-shelf, left 99400140 No 1 per year $39.95 MD, NP, OT, PT GEN
Wrist hand, off-the-shelf, right 99400142 No 1 per year $39.95 MD, NP, OT, PT GEN
Wrist hand, finger, off-the-shelf, left 99400144 No 1 per year $45.00 MD, NP, OT, PT GEN
Wrist hand finger, off-the-shelf, right 99400146 No 1 per year $45.00 MD, NP, OT, PT GEN

3.3 Head - torso - spine orthoses

Head - torso - spine orthoses – custom-fitted
Item Description Item Code Prior Approval Recommended Replacement Guidelines Maximum Price Prescriber Provider
Abdominal support 99400149 No 1 per year $64.00 MD, NP, RN, OT, PT GEN
Cervical - custom-fitted 99400151 Yes 1 every 2 years   MD, NP, PT CO(c), CPO(c), TOP
Cervical-thoracic-lumbar-sacral, custom-fitted 99400618 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP
Helmet - custom-fitted 99400154 Yes 1 every 2 years   MD, NP, OT, PT CO(c), CPO(c), TOP
Hernia truss 99400156 No 1 per year $62.00 MD, NP GEN
Lumbosacral spinal, custom-fitted 99400158 Yes 1 every 2 years   MD, NP, PT CO(c), CPO(c), TOP
Pelvic belt 99400162 No 1 per year $68.60 MD, NP, PT GEN
Thoracolumbarsacral, custom-fitted 99400164 Yes 1 every 2 years   MD, NP CO(c) CPO(c) TOP
Repairs - Head-Torso-Spine Orthoses 99400166 Yes 1 repair per year after warranty expires $150.00    CO(c) CPO(c) TOP
Head - torso - spine orthoses – custom-made
Item Description Item Code Prior Approval Recommended Replacement Guidelines Maximum Price Prescriber Provider
Cervical, custom-made 99400152 Yes 1 every 3 years   MD, NP CO(c), CPO(c), TOP
Cervical/thoracic/ lumbar/sacral, custom-made 99400619 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP
Helmet, custom-made 99400155 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP
Lumbosacral spinal, custom-made 99400159 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP
Thoracolumbarsacral custom-made 99400165 Yes 1 every 2 years   MD, NP CO(c), CPO(c), TOP
Head - torso - spine orthoses – off-the-shelf
Item Description Item Code Prior Approval Recommended Replacement Guidelines Maximum Price Prescriber Provider
Cervical, off-the-shelf 99400150 No 1 per year $25.00 MD, NP, PT GEN
Helmet, off-the-shelf 99400153 No 1 per year $65.00 MD, NP, OT, PT GEN
Lumbosacral spinal, off-the-shelf 99400157 No 1 per year $66.00 MD, NP, PT GEN
Thoracolumbarsacral, off-the-shelf 99400163 No 1 per year $61.00 MD, NP, PT GEN

3.4 Orthotic supplies

Orthotic supplies
Item Description Item Code Prior Approval Recommended Replacement Guidelines Prescriber Provider
Knee brace undersleeve 99400620 Yes 2 per year MD, NP, PT GEN
Liner socks for orthotics 99400621 Yes 6 per year MD, NP GEN
Textile sleeves 99400622 Yes 2 per year MD, NP GEN
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