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 section 1.0 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 or 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 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:

• MD — Physician
• NP — Nurse Practitioner
• OT — Occupational Therapist
• Podiatrist^{Footnote 1} — 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. Providers must be in good standing with their regulatory body. Refer to the provider section of the item tables below to identify the eligible provider of a specific item:

• Chiropodist^{Footnote 1} — Chiropodist registered with provincial or territorial regulatory bodies
• CO(c) — Certified Orthotist
• CPO(c) — Certified Prosthetist Orthotist
• GEN — Enrolled General medical supplies and equipment or Pharmacy Provider
• OT — Registered Occupational Therapist
• Podiatrist^{Footnote 1} — Podiatrists registered with provincial or territorial regulatory bodies
• PT — Registered Physiotherapist, except for PTs registered in Québec, Newfoundland and Labrador and Yukon
• TOP — Technicien en orthèses et prothèses certified by l'Ordre des technologues professionnels du Québec (OTPQ) (Québec only)

3.1.3 Prior Approval Requirements

General prior approval requirements can be found in section 1.0 General policies.

3.1.4 Exclusions

In addition to the general exclusion policy listed in section 1.0 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 or therapy equipment, such as, but not limited to:
  • electrospinal orthosis
  • neurostimulators
  • direct passive movement devices
  • electromagnetic stimulators for osseous growth
  • cryotherapies
• 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 2}
• breakage guarantee for 2 months on customized or pre-fabricated orthoses
• no charge for necessary adjustments to a customized orthosis or pre-fabricated for 30 days after the final fitting^{Footnote 2}

3.1.6 Repairs

The program will cover minor repairs to limb and body orthotic devices as an open benefit. Major repairs to limb and body orthotic devices require prior approval. Repairs that are not covered under the warranty are eligible for coverage when supported by proper documentation.

The following rules apply:

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

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.

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:

• 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
• specific measurement information: shape or volume capture of the body part for the manufacturing of the device
• manufacturing or fabricating of the device
• dispensing of the item, including necessary adjustment and fitting
• all ongoing care including follow-up visits, telephone calls and correspondence within the warranty period
• client education and instructions on the effective use, safety, and care of the equipment and supplies

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, 1 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