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 section 1.0 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 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:

• LPN/RPN — Licensed Practical Nurse/Registered Practical Nurse when within their scope of practice in their province or territory
  • In case of a renewal only: an initial prescription is required from MD, NP, NSWOC or WOCC(C)
• MD — Physician
• NP — Nurse Practitioner
• NSWOC — Nurse Specialized in Wound, Ostomy and Continence
• OT — Occupational Therapist associated with a burn unit or clinic or a plastic surgery unit or clinic (renewals only)
• PT — Physiotherapist with a burn unit or clinic and or a plastic surgery unit or clinic (renewals only)
• RM — Registered Midwife
• RN — Registered Nurse
  • In case of a renewal only: an initial prescription is required from MD, NP, NSWOC or 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 (Canada)

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:

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 section 1.0 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 or 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 section 1.0 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 or 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) such as pre and post-surgery, pre and post medical treatment and for post-traumatic oedema
• nighttime use
• osteoarthritis, to the degree of mechanical restriction
• arthritis gloves

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 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 and measurements to determine the type of benefit required manufacturing or fabricating the device
• dispensing of the item including necessary adjustments and fitting
• all ongoing care including follow-up visits, telephone calls and correspondence
• client education and instructions on the effective use, safety, and care of the equipment and supplies

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