3.0 Limb and body orthotics equipment and supplies benefits list

3.1.1 Benefit policies

General information common to all medical supplies and equipment (MS&E) can be found in the general policies.

3.1.2 Prescriber and provider requirements

Prescriptions or recommendations for coverage must be initiated by the health professionals identified as prescribers or recommenders of the specific item as listed in the tables. Items that are prescribed by prescribers/recommenders not recognized by NIHB for the specific item will lead to denials or reversal of claims.

The following is a list of NIHB-recognized prescriber/recommender abbreviations found in this segment of the benefits list. Please refer to the prescriber section of the item tables below to identify the eligible prescriber/recommender of a specific item:

• MD — Physician
• NP — Nurse Practitioner
• OT — Occupational Therapist
• Podiatrist* — Podiatrists registered with provincial or territorial regulatory bodies
• PT — Physiotherapist
• RM — Registered Midwife
• RN — Registered Nurse

The following is a list of NIHB-recognized provider abbreviations found in this segment of the benefits list. Please refer to the provider section of the item tables below to identify the eligible provider of a specific item:

• Chiropodist* — Chiropodist registered with provincial or territorial regulatory bodies
• CHT — Registered occupational therapists and physiotherapists certified by the Hand Therapy Certification Commission, Inc. (HTCC)
• CO(c) — Certified Orthotist
• CPO(c) — Certified Prosthetist Orthotist
• GEN — Enrolled General medical supplies and equipment or Pharmacy Provider
• OT – Registered Occupational Therapist, except for OTs registered in Nova Scotia
• Podiatrist* — Podiatrists registered with provincial or territorial regulatory bodies
• PT – Registered Physiotherapist, except for PTs registered in Quebec, Newfoundland and Labrador and Yukon
• 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)" (Québec only)

* Chiropodists and podiatrists must include their member class, registration number, and academic designation with their signature.

3.1.3 Prior Approval Requirements

General prior approval requirements can be found in the general policies.

3.1.4 Exclusions

In addition to the general exclusion policy listed in the general policies, the following items are excluded from the limb and body orthotics benefit and are not considered for coverage or appeal under the NIHB program:

• therapy treatment and/or therapy equipment, such as, but not limited to:
  • electrospinal orthosis
  • neurostimulators
  • direct passive movement devices
  • electromagnetic stimulators for osseous growth
• orthotics that include externally powered or microprocessor components. This exclusion also applies to the replacement of any components, client reimbursement, the coordination of benefits and all repairs for these devices

3.1.5 Warranties

The warranty must include:

• breakage guarantee for 6 months on custom-made orthoses
• no charge for necessary adjustments to custom-made orthoses for 3 months after the final fitting^{Footnote 1}
• breakage guarantee for 2 months on customized or pre-fabricated orthoses
• no charge for necessary adjustments to a customized orthosis/pre-fabricated for 30 days after the final fitting^{Footnote 1}

3.1.6 Repairs

The program will cover minor repairs to limb and body orthotics under the special authorization process. When providers submit a prior approval for a new orthosis, a special authorization will be created to allow the provider to directly claim up to the NIHB price listed in the MS&E price files for any repair required after the device warranty has expired. The special authorization will be effective from the device warranty expiration date to the device frequency limit. Repair prices are to include materials, components and labour. Special authorizations may also be set up for older orthoses when repairs are requested for the first time.

Before doing any repair, providers should confirm with Express Scripts Canada if prior approval is required. Repairs that are not covered under the warranty are eligible for coverage when supported by proper documentation.

The following rules apply:

• warranty is expired
• repairs must have a minimum warranty of 90 days
• request must include a detailed cost breakdown of materials, components, labour time and rates
• prior approval is required for repairs exceeding the recommended frequency or NIHB price

A description of all repairs with dates, detailed cost breakdown of materials, components, labour time and rates must be kept on file for each client.

Providers may submit a request for prior approval at any time for repairs that may be required over the frequency guideline or NIHB price.

Note: The NIHB program will not cover the labour cost for repairs that are covered under the warranty.

3.1.7 Replacement requirements

Recommended replacement guidelines indicate the quantity and frequency at which a benefit item will be eligible for coverage. Recommended replacement guidelines are based on a client's customary medical needs and the typical device's lifespan.

An original prescription may be used for a replacement request when ALL of the following criteria are met:

• the request is submitted by the same provider
• limb and body orthotic was initially covered by the NIHB program
• the item requested addresses the same medical condition as the original item
• the client's functional status remains unchanged
• the item is eligible for replacement as per its recommended replacement guidelines

A copy of the prescription and prescriber number must be kept in the client's file at the provider's office with all orthotic replacements.

All other requests for replacement require a new prescription.

For more general information, please see section 1.12 Recommended replacement guidelines.

3.1.8 Services included in the NIHB price

The following services must be included in the NIHB price to be considered for coverage:

• initial assessment to determine the type of benefit required
• product and material/componentry ordering and delivery from the manufacturer to the provider (including delivery costs, exchange rate)
• shape/volume capture of the body part for the manufacturing of the device
• manufacturing/fabricating of the device
• dispensing of the benefit, which includes the adjustment, fitting
• follow-up visits

3.1.9 Terminology

3.2.1 Head and neck

3.2.2 Thoracic

3.2.3 Lumbosacral

3.2.4 Other head-torso-spine orthoses

3.3.1 Shoulder

3.3.2 Elbow

3.3.3 Wrist

3.3.4 Finger

Specify which digits are within the prior approval request.

3.4.1 Hip

3.4.2 Hip-knee-ankle-foot

3.4.3 Knee

3.4.4 Patella

3.4.5 Knee-ankle-foot

3.4.6 Ankle

3.4.7 Ankle foot

3.4.8 Walking boot

• a boot made of semi-rigid material in 2 pieces (one covering the back and sides of the lower leg and the bottom of the foot, and a second piece covering the front of the lower leg and top of the foot) with a soft lining, secured to the lower leg and foot with Velcro straps
• can be mid-calf or below-knee height
• with or without adjustable air cells
• coverage is provided for a client that requires an offloading walking boot due to a medical condition for which the walking boot was deemed to be the optimum treatment after considering all factors, including reasonable access to medical treatment
• the code 99400807 – offloading diabetic walking boot should be used for diabetic clients with active plantar foot ulcers

3.6.1 Repairs

3.6.2 Delivery