Medical Supplies and Equipment Benefits List

5.0 Oxygen equipment and supplies benefits list

For information on policies regarding the provision of oxygen equipment and supplies, please consult the Guide for Medical Supplies and Equipment.

Oxygen equipment and supplies

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
PAFootnote* – Physician Assistant – (applies to Manitoba only)

Provider type:
GEN – Enrolled general MS&E or pharmacy provider
OP – Oxygen provider with required staff:
  • RRT – Registered Respiratory Therapist
  • RN – Registered Nurse
  • LPN/RPN – Licensed Practical Nurse/Registered Practical Nurse when within their scope of practice in their province/territory
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.

5.1 Oxygen equipment and supplies

Oxygen systems and equipment
Item Description Item Code Prior Approval Recommended Replacement Guidelines Prescriber Provider
Concentrator, purchase 99400473 Yes Every 5 years MD, NP, PAFootnote * OP
Concentrator with back up cylinder, rental 99400224 Yes   MD, NP, PAFootnote * OP
Homefill, purchase 99400828 Yes Every 5 years MD, NP, PAFootnote * OP
Homefill, rental 99400829 Yes   MD, NP, PAFootnote * OP
Portable concentrator, purchase, 1 battery 99400862 Yes Every 5 years MD, NP, PAFootnote * OP
Portable concentrator, rental, 1 battery 99400863 Yes   MD, NP, PAFootnote * OP
Oxygen cylinder with content, regulator, holder, cart, shoulder pouch c/s straps
Item Description Item Code Prior Approval Recommended Replacement Guidelines Prescriber Provider
Cylinder D (356 L), rental 99400227 Yes   MD, NP, PAFootnote * OP
Cylinder E (622 L), rental 99400228 Yes   MD, NP, PAFootnote * OP
Cylinder H or K (6900 L), rental 99400232 Yes   MD, NP, PAFootnote * OP
Cylinder S or M (5260 L), rental 99400231 Yes   MD, NP, PAFootnote * OP
Additional oxygen cylinder without content, regulator, holder, cart, shoulder pouch
Item Description Item Code Prior Approval Recommended Replacement Guidelines Prescriber Provider
Cylinder D (356 L), rental 99400631 Yes   MD, NP, PAFootnote * OP
Cylinder E (622 L), rental 99400632 Yes   MD, NP, PAFootnote * OP
Cylinder H or K (6900 L), rental 99400634 Yes   MD, NP, PAFootnote * OP
Cylinder S or M (5260 L), rental 99400633 Yes   MD, NP, PAFootnote * OP
Dual system, without content, rental 99400635 Yes   MD, NP, PAFootnote * OP
Dual system with content, rental 99400636 Yes   MD, NP, PAFootnote * OP
Liquid oxygen system (without content) include portable & cart, rental 99400225 Yes N/A MD, NP, PAFootnote * OP
Maintenance agreement, for purchased oxygen systems 99400638 Yes Negotiable   OP
Oxygen conserving device, rental 99400544 Yes   MD, NP, PAFootnote * OP
Oxygen systems, Repairs 99400243 Yes     OP

5.2 Oxygen supplies

Oxygen supplies
Item Description Item Code Prior Approval Recommended Replacement Guidelines Prescriber Provider
Battery, replacement (portable concentrator) 99400864 Yes 2 per year   OP
Distilled water 99400626 No 4L containers/55 per year MD, NP, PAFootnote * GEN, OP
Disposables (plastics)Footnote **
Item Description Item Code Prior Approval Recommended Replacement Guidelines Prescriber Provider
Extension oxygen tubing 25 ftFootnote ** 99400234 Yes 4 per year MD, NP, PAFootnote * OP
Extension oxygen tubing 50 ftFootnote ** 99400214 Yes 4 per year MD, NP, PAFootnote * OP
E-Z WrapFootnote ** 99400235 Yes 24 per year MD, NP, PAFootnote * OP
Filters for concentratorFootnote ** 99400220 No 12 per year MD, NP, PAFootnote * OP
Humidifier (bubble)Footnote ** 99400237 No 6 per year MD, NP, PAFootnote * OP
MasksFootnote ** 99400238 No 24 per year MD, NP, PAFootnote * OP
Masks (tracheostomy)Footnote ** 99400627 No 24 per year MD, NP, PAFootnote * OP
Nasal CannulaFootnote ** 99400239 No 24 per year MD, NP, PAFootnote * OP
Oxygen connectors/ adaptorsFootnote ** 99400207 No   MD, NP, PAFootnote * OP
Water TrapsFootnote ** 99400545 No 2 per year MD, NP, PAFootnote * OP
Gas content only (for cylinders)
Item Description Item Code Prior Approval Recommended Replacement Guidelines Prescriber Provider
Cylinder D (356 L) 99400221 Yes   MD, NP, PAFootnote * OP
Cylinder E (622 L) 99400226 Yes   MD, NP, PAFootnote * OP
Cylinder H or K (6900 L) 99400230 Yes   MD, NP, PAFootnote * OP
Cylinder S or M (5260 L) 99400229 Yes   MD, NP, PAFootnote * OP
Liquid oxygen (in kg) 99400233 Yes Calculated as per prescription and mobility of client MD, NP, PAFootnote * OP
Oxygen delivery service 99400262 Yes     OP
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