6.0 Pressure devices equipment and supplies benefits list

6.1.1 Benefit policies

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

6.1.2 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:

• LPN/RPN — Licensed Practical Nurse/Registered Practical Nurse when within their scope of practice in their province/territory (renewals only)
• 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 — Registered Nurse (renewals only - 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

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:

Compression garments:

• GEN-CCGF — Enrolled general MS&E or pharmacy provider with staff certified as a compression garment fitter

Hypertrophic scar pressure garments:

• GEN-CCGF/CBSGF — Enrolled general MS&E or pharmacy provider with staff certified as compression garment fitter or certified burn scar garment fitter

6.1.3 Prior approval requirements

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

To initiate the prior approval process, the Pressure Devices Prior Approval Form or the Compression Stockings Prior Approval Form, found on the Express Scripts Canada NIHB provider and client website, must be completed in full and submitted to your NIHB regional office along with the following supporting documentation:

• the prescription or recommendation or referral form listing the required compression signed by an NIHB-recognized prescriber for the requested benefit
• additional relevant information the provider/physician, nurse practitioner or registered midwife may have to support the request
• medical grade stockings must be fit by a certified fitter of compression garments. Proof of certification should be kept on file and may be required by the program
• whether the item is custom-fitted or custom-made
• exact client measures are required for custom-made items
• name of the manufacturer and model of the item
• an explanation of benefits from any third-party coverage available to the client (for example, provincial plan, workers' compensation board, private insurance, education plan, etc.)

6.1.4 Exclusions

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

• stockings for comfort only, or recreational purposes
• stockings with a degree of compression lower than 20 mmHg (for example, 10-20 mmHg)
• non-medical support hosiery including sport compression socks
• acute and active treatment (initial edema reduction before achieving dry/stable state preceding stocking fitting) including sclerotherapy, edema management, systemic edema, deep vein thrombosis (DVT), emboli or arterial blood clots, cellulitis, thrombophlebitis, phlebitis, post phlebitis syndrome, arterial insufficiency, hypotension
• prevention, such as thromboembolism-deterrent (TED) stockings
• compression stockings for short-term management (less than 6 months)
• nighttime use
• osteoarthritis, to the degree of mechanical restriction

6.1.5 Warranties

Providers must honour the manufacturer's warranty.

6.1.6 Repairs

Repairs that are not covered under the warranty are eligible for coverage when supported by proper documentation.

The following rules apply:

• prior approval is required
• request must include detailed cost breakdown of parts, labour time and rates
• repairs must have a minimum warranty of 90 days

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

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

6.1.7 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.

Replacement is subject to the same process as the original purchase.

All replacement requests require a new prescription.

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

6.1.8 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 type of benefit required
• measuring body part to manufacture the device in precise measurement
• manufacturing the device
• dispensing the benefit, including adjustment and fitting
• follow-up visits, as per professional/industry standards
• product and parts ordering and delivery from manufacturer to provider (including delivery costs, exchange rate)

6.1.9 Terminology

6.2.1 Sleeve

6.2.2 Glove

6.2.3 Stocking

6.2.4 Bandages

NIHB does not cover any specific brand and the list below is not exhaustive. The items listed are examples that may be considered for coverage in this category.

6.3.1 Head

6.3.2 Arm

6.3.3 Elbow

6.3.4 Half sleeve

6.3.5 Body

6.3.6 Chap

6.3.7 Knee-foot

6.3.8 Anklet

6.3.9 Foot

6.3.10 Other

6.4.1 Sequential pump

Indicate site and cause of lymphedema on prior approval request.

6.5.1 Delivery