7.0 Prosthetics equipment and supplies benefits list

7.1.1 Benefit policies

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

7.1.2 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:

• BCO — Board Certified Ocularist
• MD — Physician
• NP — Nurse Practitioner
• OD — Optometrist
• OPH — Ophthalmologist
• 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:

• 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)" (Québec 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-CCGF — enrolled general MS&E or pharmacy provider with staff certified as a compression garment fitter

7.1.3 Prior approval requirements

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

To initiate the prior approval process, the Prosthetics 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:

For all prostheses:

• the prescription/recommendation or referral form signed by an NIHB-recognized prescriber for the requested benefit
• the medical diagnosis
• the date of surgery
• a detailed assessment
• an itemized quote (including manufacturer name, item number and size if applicable, manufacturer description and cost)
• additional relevant information the provider or prescriber may have to support the request
• an explanation of benefits from any third-party coverage available to the client (for example, provincial plan, workers' compensation board, private insurance, education plans, etc.)

For limb prosthesis:

• information on the functional potential evaluation and the measures used (for example, predictive or functional measurements, standing balance, current mobility aids required, weight changes, volume changes, etc.) to support prior approval requests
• rationale to support that the requested modular components including prosthetic foot and/or knee are appropriate for the client's functional potential or abilities
• include all prosthetic components, adapters and prosthetic procedures requested (such as preparatory socket, definitive transtibial socket, definitive suction procedure, etc.) and include the foot selection and knee unit

Please note: The NIHB program provides coverage for cost-effective devices and components that meet the justified medical needs of the client. Cost-effective refers to the most economical device or component that is medically necessary to meet the client's essential functional needs.

7.1.4 Exclusions

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

• eye prosthesis:
  • a second ocular prosthesis for the same site when the first prosthesis is still functional and within recommended replacement guidelines
  • modifications and adjustments for cosmetic reasons
  • prosthetic implants (for example, hydroxyapatite) and attachment posts ocular
  • prostheses fabricated by a non-certified provider
• breast prosthesis:
  • temporary or swim prosthesis
  • silicone implants used in breast reconstruction
  • breast prosthesis for failed breast reconstruction, when the client has not had a mastectomy or lumpectomy
  • breast prosthesis for cosmetic augmentation
  • silicone nipples
• limb prosthesis:
  • a prosthesis that includes any externally powered or microprocessor components (for example, myoelectric prosthesis). This exclusion also applies to the replacement of any components, client reimbursement, the coordination of benefits and repairs
  • a second prosthesis for the same amputation site
  • early replacement of a prosthetic device that has been used beyond manufacturer specifications (for example, for weightlifting or sports)
• testicular implants
• wigs and hairpieces

7.1.5 Warranties

Providers must honour the manufacturer's warranty.

In addition:

• for breast prostheses:
  • the warranty must guarantee that the prosthesis will remain satisfactory for fit and defects for a minimum of 2 years
• for an eye prosthesis:
  • no modifications or repairs will be covered to an ocular prosthetic device within 90 days of provision of the prosthetic device. The provider will provide all necessary follow-ups to ensure the device can be used for the purpose intended without additional cost to NIHB or the client
  • during those 90 days, the provider must ensure that the fit of the ocular prosthesis remains satisfactory if there is no change in the client's ocular medical condition or growth/atrophy of the client's orbital cavity
  • the warranty must guarantee against discoloration and delamination of the materials for one year from the date the completed ocular prosthesis is delivered to the client. In such situations, the provider must arrange any service, including repairs, cleaning or replacement of the device, free of charge
• for limb prostheses:
  • no charge for necessary adjustments for 3 months after the final fitting provided that the individual's size or medical condition has not changed significantly, and the warranty must guarantee against breakage for 6 months
  • components that are eligible for warranty (for example, feet, knees, vacuum pumps, liners, etc.) will be registered as required by the manufacturer by the provider. Documentation to support registration may be requested if early repair or replacement is requested
  • components (for example, feet, knees, vacuum pumps, liners, etc.) that require repair or replacement that are covered under warranty must be serviced by the manufacturer

7.1.6 Repairs

The program will cover minor repairs to prosthetics under a special authorization process. When providers submit a prior approval for a new prosthesis or request a repair to an existing device, 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 subsequent repairs. The special authorization will be effective from the device warranty expiration date to the device frequency limit. Repair prices include parts and labour.

Prior to performing a repair, the provider must communicate with Express Scripts Canada to confirm 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:

• prior approval is required for repairs exceeding the NIHB price or frequency
• 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.

7.1.7 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.

An original prescription may be used for initial and replacement requests of both prosthesis and prosthetic supplies when ALL of the following criteria are met:

• the request is submitted by the same provider
• the prosthesis was initially covered by the NIHB program
• the prosthesis requested addresses the same medical condition as the original prosthesis
• the client's functional status remains the same
• 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 for all prosthetic replacements.

All other requests for replacement require a new prescription.

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

7.1.8 Services included in the NIHB price

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

• assessment
• product or parts ordering and delivery from manufacturer/supplier to provider (including delivery costs, exchange rate)
• casting or scanning of the body part to design the prosthesis
• fabrication and aligning components of the prosthesis
• evaluation, any adjustments to optimize function or fit
• client education on prosthesis use and final dispensing of prosthesis
• follow-up visits, as per professional association guidelines

7.1.9 Terminology

7.2.1 Ocular

Coverage criteria:

• an eye prosthesis is covered to restore the anatomy of an eviscerated or enucleated socket
• a scleral shell is covered for a sightless, shrunken eye or severe dry eye
• a conformer is covered for treating children with anophthalmia or microphthalmia, after eye removal surgery (evisceration/enucleation), and adults with mild to severe socket contraction
• the enlargement, reduction, or refitting is covered to align with anatomical changes in the soft tissue of the orbit over time or to correct a poor fitting
• polishing/resurfacing of a scleral shell or ocular prosthesis is covered as a preventive measure to remove scratches and prevent the build-up of protein and other possible ocular irritants

7.2.2 Breast

Note: Breast prosthesis is to be dispensed within 6 weeks from the date of the surgical procedure.

7.3.1 Fore quarter

7.3.2 Shoulder

7.3.3 Transhumeral

7.3.4 Elbow

7.3.5 Transradial

7.3.6 Wrist

7.3.7 Partial hand

7.3.8 Finger

7.4.1 Diagnostic socket

• may also be referred to as interim, temporary, check or test socket
• may be dynamic or static, laminated or non-laminated, and made of various materials
• is used to assess and adjust/optimize socket/residuum interface for optimal comfort, function, and alignment

7.4.2 Final diagnostic socket

• is a finalized socket created for either a preparatory or definitive prosthesis
• serves as a template for the definitive treatment
• is coded with the applicable preparatory or definitive code

7.4.3 Preparatory prosthesis

• is provided during the early phase of rehabilitation for a short period (usually less than 1 year), until the residuum volume has stabilized
• consists of a prosthetic socket molded over the positive anatomical model of the patient's residuum and attached to components to allow ambulation
• includes modular components that are reused with a definitive prosthesis. Loaned components can be utilized with a preparatory prosthesis, but do not include an endoskeleton cover
• is a means to establish whether a patient will benefit from a definitive prosthesis

7.4.4 Definitive prosthesis

• is provided once residual limb volume has stabilized and the final prosthetic components and design have been determined via preparatory prosthesis use
• consists of a prosthetic socket, molded over the positive anatomical model of the patient's residuum and attached to components to allow ambulation
• may include an anatomical cover, depending on the patient's preference

7.4.5 Information required for initial prosthesis

Requesting an initial prosthesis requires supporting information, with an explanation beyond simply stating 'first or initial prosthesis'. The following details must be provided to explain the need for the initial prosthesis:

• the assessment that was used to determine that the client will be a successful prosthetic user
• the pertinent information regarding cognition, motivation, strength, range of motion and any contractures present
• information regarding gait and mobility for example, documented functional potential, standing balance, ability to hop 10 meters in parallel bars, mostly required for home use, or community use, only required for transferring
• special considerations for their current health, age, etc.

7.4.6 Information required for a definitive prosthesis

Request for a definitive prosthesis will be considered once prosthetic rehabilitation with a preparatory prosthesis has been completed, and the client is progressing in rehabilitation. The definitive prosthesis request should include an update on any changes in the client's level of function. Please note that the prosthetic foot, knee joint, and suitable modular components are expected to be reused when a client transitions to a definitive prosthesis.

Specific justification/rationale is required for the following situations:

• when modular components from a preparatory prosthesis are not being reused with a definitive prosthesis
• when more than 2 diagnostic sockets (regardless of static or dynamic design) are requested with a preparatory or definitive prosthesis. This may include but is not limited to physiological change, growth, and change in medical condition or minor surgery. Physiological change must be specifically stated and quantified as appropriate

7.4.7 Hip

7.4.8 Transfemoral

7.4.9 Knee

7.4.10 Transtibial

7.4.11 Ankle

7.4.12 Foot

7.4.13 Socket

7.5.1 Sleeves

7.5.2 Liners

7.5.3 Sheaths

7.5.4 Socks

7.5.5 Other

7.6.1 Repairs

7.6.2 Delivery