Medical Supplies and Equipment Benefit Lists

7.0 Prosthetics benefits list

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

Prosthetics 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
OPH – Ophthalmologist
RN – Registered Nurse
Provider type:

CP(c) – Certified Prosthetist
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)
BCO – Board Certified Ocularist
CMF – Provider must be or must employ a Certified Mastectomy Fitter
GEN – Enrolled general MS&E or pharmacy provider
GEN-GEN-CCGF – enrolled general MS&E or pharmacy provider with staff certified as a compression 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.

7.1 Breast prosthesis

Breast prosthesis
Item Description Item Code Prior Approval Recommended Replacement Guidelines Prescriber Provider
Brassiere (breast prosthesis) 99400002 Yes 2 per 2 years MD, NP, RN CMF
Breast prosthesis, right 99400800 Yes 1 every 2 years MD, NP, RN CMF
Breast prosthesis, left 99400801 Yes 1 every 2 years MD, NP, RN CMF
Partial breast prosthesis 99400003 Yes 1 every 2 years MD, NP, RN CMF

7.2 Eye prosthesis (ocular)

Eye prosthesis (ocular)
Item Description Item Code Prior Approval Recommended Replacement Guidelines Maximum Price PrescriberFootnote * Provider
Eye prosthesis, adjustment, right 99401205 Yes 1 per year Price File   BCO
Eye prosthesis, adjustment, left 99401185 Yes 1 per year Price File   BCO
Eye prosthesis, left 99400005 Yes 1 every 3 years Price File OPH BCO
Eye prosthesis, right 99400006 Yes 1 every 3 years Price File OPH BCO
Eye prosthesis-polishing, right 99401204 No 1 per year Price File   BCO
Eye prosthesis-polishing, left 99401184 No 1 per year Price File   BCO
Scleral shell, left 99400802 Yes 1 every 3 years Price File OPH BCO
Scleral shell, right 99400803 Yes 1 every 3 years Price File OPH BCO

7.3 Limb prostheses

Prosthetics - limbs - lower extremity - definitive
Item Description Item Code Prior Approval Recommended Replacement Guidelines Maximum price PrescriberFootnote * Provider
Ankle disarticulation, left 99400014 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Ankle disarticulation, right 99400015 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Hemipelvectomy or hip disarticulation, left 99400022 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Hemipelvectomy or hip disarticulation, right 99400023 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Knee disarticulation (through knee), right 99400019 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Knee disarticulation (through knee), left 99400018 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Partial foot - shoe insert, left 99400008 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Partial foot - shoe insert, right 99400009 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Partial foot - tibial tubercle height, left 99400010 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Partial foot - tibial tubercle height, right 99400011 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Partial foot, patella tendon bearing, left 99400012 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Partial foot, patella tendon bearing, right 99400013 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Repairs prosthetic lower limb, left 99401186 Yes 1 per yearFootnote 2 ** $250.00   CP(c), CPO(c), TOP
Repairs prosthetic lower limb, right 99401206 Yes 1 per yearFootnote 2 ** $250.00   CP(c), CPO(c), TOP
Replace foot for AK & BK, left 99400831 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Replace foot for AK & BK, right 99400832 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Replace socket for AK & BK, left 99400833 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Replace socket for AK & BK, right 99400834 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Transfemoral - above knee, left 99400020 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Transfemoral - above knee, right 99400021 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Transtibial - below knee, left 99400016 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Transtibial - below knee, right 99400017 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Prosthetics - limbs - lower extremity - preparatory
Item Description Item Code Prior Approval Recommended Replacement Guidelines Maximum price PrescriberFootnote * Provider
Ankle disarticulation, left 99400553 Yes     MD, NP CP(c), CPO(c), TOP
Ankle disarticulation, right 99400554 Yes     MD, NP CP(c), CPO(c), TOP
Hemipelvectomy or hip disarticulation, left 99400561 Yes     MD, NP CP(c), CPO(c), TOP
Hemipelvectomy or hip disarticulation, right 99400562 Yes     MD, NP CP(c), CPO(c), TOP
Knee disarticulation, left 99400557 Yes     MD, NP CP(c), CPO(c), TOP
Knee disarticulation, right 99400558 Yes     MD, NP CP(c), CPO(c), TOP
Transfemoral, left 99400559 Yes     MD, NP CP(c), CPO(c), TOP
Transfemoral, right 99400560 Yes     MD, NP CP(c), CPO(c), TOP
Transtibial, left 99400555 Yes     MD, NP CP(c), CPO(c), TOP
Transtibial, right 99400556 Yes     MD, NP CP(c), CPO(c), TOP
Prosthetics - limbs - upper extremity
Item Description Item Code Prior Approval Recommended Replacement Guidelines Maximum price PrescriberFootnote * Provider
Elbow disarticulation, left 99400033 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Elbow disarticulation, right 99400034 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Finger, multiple digits, left 99400835 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Finger, multiple digits, right 99400836 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Finger, single digit, left 99400837 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Finger, single digit, right 99400838 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Fore quarter, left 99400039 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Fore quarter, right 99400040 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Partial hand, finger remaining, left 99400025 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Partial hand, finger remaining, right 99400026 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Partial hand, thumb remaining, left 99400027 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Partial hand, thumb remaining, right 99400028 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Repairs prosthetic upper limb, left 99401187 Yes 1 every 2 yearsFootnote 2 ** $250.00   CP(c), CPO(c), TOP
Repairs prosthetic upper limb, right 99401207 Yes 1 every 2 yearsFootnote 2 ** $250.00   CP(c), CPO(c), TOP
Shoulder disarticulation, left 99400037 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Shoulder disarticulation, right 99400038 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Transhumeral above elbow, left 99400035 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Transhumeral above elbow, right 99400036 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Transradial below elbow, left 99400031 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Transradial below elbow, right 99400032 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Wrist disarticulation, left 99400029 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP
Wrist disarticulation, right 99400030 Yes 1 every 3 years   MD, NP CP(c), CPO(c), TOP

7.4 Prosthetic supplies

Sleeves
Item Description Item Code Prior Approval Recommended Replacement Guidelines Prescriber Provider
Suction seal suspension sleeve, left 99401189 Yes 6 per year MD, NP CP(c), CPO(c), TOP
Suction seal suspension sleeve, right 99401209 Yes 6 per year MD, NP CP(c), CPO(c), TOP
Suspension sleeve, left 99401188 Yes 10 per year MD, NP CP(c), CPO(c), TOP
Suspension sleeve, right 99401208 Yes 10 per year MD, NP CP(c), CPO(c), TOP
Liners
Item Description Item Code Prior Approval Recommended Replacement Guidelines Prescriber Provider
Pin system suspension liners, left 99401191 Yes 3 per year MD, NP CP(c), CPO(c), TOP
Pin system suspension liners, right 99401211 Yes 3 per year MD, NP CP(c), CPO(c), TOP
Prosthesis liners gel, left 99401190 Yes 3 per year MD, NP CP(c), CPO(c), TOP
Prosthesis liners gel, right 99401210 Yes 3 per year MD, NP CP(c), CPO(c), TOP
Sheaths
Item Description Item Code Prior Approval Recommended Replacement Guidelines Prescriber Provider
Prosthesis sheaths regular, left 99401192 Yes 12 per year MD, NP CP(c), CPO(c), TOP
Prosthesis sheaths regular, right 99401212 Yes 12 per year MD, NP CP(c), CPO(c), TOP
Prosthesis silo sheaths, left 99401193 Yes 8 per year MD, NP CP(c), CPO(c), TOP
Prosthesis silo sheaths, right 99401213 Yes 8 per year MD, NP CP(c), CPO(c), TOP
Replacement cosmetic, hose left 99401194 Yes 2 per year MD, NP CP(c), CPO(c), TOP
Replacement cosmetic, hose right 99401214 Yes 2 per year MD, NP CP(c), CPO(c), TOP
Socks
Item Description Item Code Prior Approval Recommended Replacement Guidelines Prescriber Provider
Gel stump socks, left 99401199 Yes 2 per year MD, NP CP(c), CPO(c), TOP
Gel stump socks, right 99401219 Yes 2 per year MD, NP CP(c), CPO(c), TOP
Filler cotton socks 1 ply, left 99401197 Yes 12 per year MD, NP GEN, CP(c), CPO(c), TOP
Filler cotton socks 1 ply, right 99401217 Yes 12 per year MD, NP GEN, CP(c), CPO(c), TOP
Prosthetic glove standard, left 99401198 Yes 3 per year MD, NP GEN, CP(c), CPO(c), TOP
Prosthetic glove standard, right 99401218 Yes 3 per year MD, NP GEN, CP(c), CPO(c), TOP
Prosthesis stump shrinkers, left 99401195 Yes 4 per year MD, NP GEN-CCGF, CP(c), CPO(c), TOP
Prosthesis stump shrinkers, right 99401215 Yes 4 per year MD, NP GEN-CCGF, CP(c), CPO(c), TOP
Prosthesis stump socks, reg, left 99401196 Yes 12 per year MD, NP GEN, CP(c), CPO(c), TOP
Prosthesis stump socks, reg, right 99401216 Yes 12 per year MD, NP GEN, CP(c), CPO(c), TOP
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