13.0 Medical surgical equipment and supplies benefits list

13.1.1 Benefit policies

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

13.1.2 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 or recommenders not recognized by NIHB will lead to denials or reversal of claims.

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

• LPN/RPN — Licensed Practical Nurse or Registered Practical Nurse when within their scope of practice in their province or territory, renewals only
• MD — Physician
• NP — Nurse Practitioner
• NSWOC — Nurse Specialized in Wound, Ostomy and Continence
• RN renewals only — Registered Nurse, initial prescription required from MD, NP, NSWOC, WOCC(C)
• OT — Occupational Therapist
• PT — Physiotherapist
• RM — Registered Midwife
• RN — Registered Nurse
• 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. Refer to the provider section of the item tables below to identify the eligible provider of a specific item:

• 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

13.1.3 Prior approval requirements

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

To initiate the prior approval process, the Medical Surgical 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 signed by an NIHB-recognized prescriber for the requested benefit
• detailed assessment as required
• additional relevant information the provider, physician, nurse practitioner, occupational therapist, or physiotherapist 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 plan, etc.

13.1.4 Exclusions

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

• environmental protection devices and supplies, for example, air cleaners, filters, UV protection garments and lotions, etc.

13.1.5 Warranties

Providers must honour the manufacturer's warranty.

13.1.6 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 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.

13.1.7 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, see section 1.12 Recommended replacement guidelines.

13.1.8 Services included in the NIHB price

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

• product and parts ordering, and delivery from manufacturer to provider, including delivery costs, exchange rate
• dispensing of the benefit, which includes any required adjustments or fittings

13.1.9 Terminology

13.2.1 Diapers and liners

The following information is required when requesting coverage for diapers and liners:

• prior approval form including items listed in section 13.1.3 Prior approval requirements
• medical diagnosis that is the causes of the incontinence
• type of incontinence, bladder, bowel, or both
• when the incontinence occurs day or night
• type of incontinence supplies needed
• size of the incontinence supplies requested, does not apply to children's sizes or liners
• quantity of incontinence supplies needed
• other supporting information, for example, temporary or permanent condition

If there is a substantial change in the client's condition requiring a variation in frequency or a change in requested supplies, a new incontinence assessment should be submitted.

13.2.2 Underpads

The following information is required when requesting coverage for underpads:

• prior approval form including items listed in section 13.1.3 Prior approval requirements
• type of incontinence supplies needed, washable or disposable underpads
• size of the incontinence supplies requested
• quantity of incontinence supplies needed
• incontinence only:
  • medical diagnosis that is the causes of the incontinence
  • type of incontinence, bladder, bowel, or both
  • when the incontinence occurs day or night
  • other supporting information, for example, temporary or permanent condition
• ostomy only:
  • medical diagnosis or type of ostomy, for example, colostomy, ileostomy, urostomy
  • other supporting information, for example, temporary or permanent condition
• wound care only:
  • diagnosis, wound type
  • wound location and wound size
  • other supporting information, for example, frequency of dressing change per wound, wound irrigation needs

If there is a substantial change in the client's condition requiring a variation in frequency or a change in requested supplies, a new incontinence or ostomy assessment should be submitted.

13.2.3 Catheters

13.2.4 Devices

13.3.1 One-piece pouch

13.3.2 Two-piece pouch

13.3.3 Ostomy supplies

13.4.1 Adhesive

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

13.4.2 Alginates, hydrofibres and poly-absorbent fibres dressing

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

13.4.3 Bandage

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

13.4.4 Compression bandages

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

13.4.5 Charcoal dressing

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

13.4.6 Composite dressing

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

13.4.7 Eye

13.4.8 Foam adhesive dressing

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

13.4.9 Gauze

13.4.10 Gel dressing

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

13.4.11 Honey dressing

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

13.4.12 Hydrocolloid dressing

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

13.4.13 Iodine dressing

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

13.4.14 Non-adherent dressing

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

13.4.15 Silver dressing

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

13.4.16 Transparent dressing

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

Sterile dressing tray:

Sterile dressing trays are covered for dressings changed with a sterile technique. Sterile dressing trays are not covered for dressings that can be changed with a no-touch or clean technique.

The following information is required with every sterile dressing tray request:

• prior approval form including items listed in section 13.1.3 Prior approval requirements
• item make, model, manufacturer product code, quantity and cost
• prescription or recommendation. The Wound Care Assessment Form, when completed by an NIHB recognized prescriber or recommender for the requested item, is accepted as the recommendation or prescription for this item and a separate prescription or recommendation is not required
• frequency of dressing change
• client diagnosis, wound type :
  • examples of conditions and wound characteristics when sterile dressing trays are considered for coverage:
    • central line insertion site
    • chemotherapy or radiation recipient, up to 1 year since the last treatment date. Date must be provided
    • conservative sharp debridement when performed. The frequency must be provided
    • hemodialysis fistula until healed or matured
    • nonsurgical sinus or wound that connects to a body cavity, organ, tendon or bone
    • recipient of an organ or stem cell transplant taking antirejection or immunosuppression medication
    • stage IV pressure injury
    • surgical wound for up to 1 month after the date of surgery. Date must be provided
    • third degree burns
    • ulcer secondary to arterial occlusion
    • wound packing appropriate for wounds greater than 0.5 cm in depth
  • requests for wounds not listed above will be reviewed on a case-by-case basis. Supporting information should be submitted for consideration
  • a client with an infection may be eligible for coverage on a case-by-case basis. Supporting information should be submitted for review including the specific diagnosis, for example, cellulitis. Note that simply stating infection is insufficient information to support coverage
  • NIHB does not cover sterile dressing changes for clients at risk of infection
• any additional relevant information, for example, associated condition or medical justification to support the request

Wound care-related information can be submitted as part of the Wound Care Assessment Form, found on the Express Scripts Canada provider and client website.

13.6.1 Delivery