Medical Supplies and Equipment Bulletin July 2001

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The Non-Insured Health Benefits (NIHB) Program provides supplementary
health benefits, including Medical Supplies and Equipment, to
eligible First Nations and Inuit throughout Canada.

Welcome to the second edition of the Non-Insured Health Benefits (NIHB) Medical Supply and Equipment (MS & E) Bulletin. This Bulletin provides an overview of revisions made since April 1, 2001, in all MS & E benefit areas, that will be effective July 1, 2001.

The policy and benefit changes have been identified below by benefit category. Please review this bulletin and the revised benefit list closely in order to minimize any difficulties in obtaining prior approval or billing for benefits.

Audiology Benefits

Several federal departments, including Health Canada (NIHB Program) have entered into an agreement with the Canadian Auditory Equipment Association (CAEA). The NIHB program has adopted the CAEA device prices and warranty offered under the agreement. Therefore, audiology service providers must honor the pricing schedule established under this agreement as communicated to all providers May 15, 2001. Providers are also required to send a copy of the manufacturer's invoice along with the NIHB Hearing Aid and Hearing Aid Repair Confirmation Form to the First Nations and Inuit Health Branch (FNIHB) regional office. There are no changes to the audiology policies and prior approval process since April 1, 2001. For those providers in British Columbia, please continue to follow the July 2000, Hearing aid Program, Policies, Procedures and Standards Manual. For Ontario residents, providers must first contact the Assistive Devices Program of the Ontario Ministry of Health to access benefits.

Requests for approval or hearing aids and services, with the exception of hearing aid batteries and repairs, must include a medical prescription. A medical prescription is required to rule out medical conditions other than hearing loss and to support the need for assessment by an audiologist or other hearing aid specialist. The audiologist or other hearing aid specialist will determine the type of device required to meet the client's needs. Hearing aid batteries can be provided through audiology or pharmacy providers. Up to 12 hearing aid batteries per aid every 3 months can be provided through audiology or pharmacy providers.

The replacement earmold and impression fee guideline has been changed to one every two years for adults only.

The benefit list has been expanded to include:

• a complete hearing assessment (performed bilaterally) initiated by a physician prescription. The assessment which is done in conjunction with the provision of a hearing aid should be included as part of the Fitting/ Dispensing fee. A complete hearing assessment performed after an aid has been provided and before a 5 year period has lapsed, can be billed separately for medical or other valid reasons. A prior approval and written justification is required.
• hearing aid performance check/ readjustment of hearing aid
• hearing re-assessment (partial) with medical prescription
• minor in-office services with or without supplies, without prior approval

General MS&E Benefits

For all Medical Supplies and Equipment, please provide the product name and product number on the PA form.

When a prior approval is set up for a one-year period, billing must be in accordance with client usage. Multiple dispenses must be provided and billed for no more than a three month period at a time.

Please review the revised list carefully as a significant number of benefit items have been added. An overview of the additions follows:

Bathing and Toileting Aids

• Grab bar for tub

• feeding pump bags (1500ml)
• gravity feeding supplies
• expansion of enteral feeding supplies

Miscellaneous MS & E Benefits

• Electric breast pump rental

• manual wheelchair, conventional rental
• list of wheelchair cushions and parts has been expanded significantly

Ostomy Supplies and Devices and Catheter Supplies and Equipment

• a significant revision of the codes for items in these categories

Incontinence Supplies

• list of diapers expanded to reflect age and size

Dressings

• list of gauze dressings expanded to reflect specific sizes

Orthotics and Custom Footwear

Limb and Body Orthotic Devices

Following are policy clarification or additions:

The product name and product number must be provided on the PA form.

Pharmacists and MS & E providers can provide Class I (soft) orthotics for the neck, abdomen, and in some cases for wrist/ hand and elbows and orthotic supplies such as knee brace undersleeve, socks and textile sleeve with a medical prescription and prior approval. All other body and limb Class I (soft) orthotics must be provided by a Certified Orthotist.

Orthoses for spinal fractures with a specialist prescription can be submitted for post approval.

Oncologists have been added as prescribers for orthotics and prosthetics.

While it is recognized that access to a medical specialist may be an issue in some areas, a prescription from a specialist is required for the first issue of a body or limb orthotic device. A prescription from a general practitioner will be accepted for a replacement of the same type of device. Please note, if the replacement is required due to a medical change, loss or irreparable damage and is required before the recommended replacement guideline period, a new prescription from a medical specialist will be required.

Correction to the February 2001 NIHB Bulletin: Certified Prosthetists CP(c) are not recognized providers for Class II and III orthotics.

Changes to the benefit list include addition of:

• Lower and Upper Extremity Limb Orthoses
• Head-Torso-Spine Orthoses
• Orthotic Supplies

Custom Made Footware, Custom Made Internal Footware Devices and Modifications to Stock Footware

Prescribers for custom footwear must be a medical specialist or surgical specialist. The casting technique must be included on the prior approval form. Foam box casing is only accepted for accommodative devices. For all functional devices only plaster of paris bandage casting or contact digitalizing will be accepted. Laser and optical scans of the foot are not accepted for any devices.

For custom made footwear all prior approval applications must be accompanied by a prescription from a recognized prescriber. For new applications, a tracing of the foot or a digital or Polaroid photograph is required (photographs are preferred over tracings). For replacement footwear, a tracing of the foot and/ or the cast or lasts.

While it is recognized that access to a medical specialist may be an issue in some areas, a prescription from a specialist is required for the first issue of custom made footwear. A prescription from a general practitioner will be accepted for a replacement of custom made footwear. Please note, if the replacement is required due to a medical change, loss or irreparable damage and is required before the recommended replacement guideline period, a new prescription from a medical specialist will be required.

Changes to the benefit list include addition of:

• Repairs to custom made footwear
• Custom made internal footwear devices, pair
• Repairs to footwear modifications

Oxygen and Respiratory Supplies

The following are policy clarification or changes:

Clients living 250 km or more away from a centre with a blood gas machine are eligible for oxygen for up to 3 months if oximetry testing with Sp02 is less than 89% for two consecutive minutes at rest for the February 2001 NIHB Bulletin criteria (a) (a resting Pa02 on room air equal or less than 55 mm Hg) and Sp02 is less than 90% for criteria (b) (a resting Pa02 on room air between 56 and 59 mm Hg, when there is evidence of cor pulmonale, pulmonary hypertension or secondary polycythemia) (c) exercise limitation due to hypoxemia with significantly greater exercise capability and/ or significantly decreased shortness of breath on oxygen compared to room air (confirmed by objective data) and (d) nocturnal hypoxemia when nocturnal oxygen desaturation is less than 88% for 30% of the night in spite of appropriate CPAP or bilevel therapy). Each print-out must record 5 continuous minutes of moni toring and must indicate a consistent saturation. An arterial blood gas must be done within 3 months of the initiation of therapy.

Physicians ordering oxygen therapy for palliative reasons where life expectancy is less than 3 months must clearly indicate so. The term "cancer" alone, will not be interpreted as being a palliative condition. If oxygen is required after a 3 month period the medical eligibility criteria must be met and an ABG submitted accordingly.

In cases where the applicant is 18 years of age or less, an oximetry test with Sp02 less than 92% for two consecutive minutes at rest is required. Each print-out must record 5 continuous minutes of monitoring and must indicate a consistent saturation. Capillary gases will also be accepted if available. Improvement of the applicant's condition with the use of oxygen should be documented. Special consideration may be given to children who are unable to tolerate room air testing. Prescriber must submit saturation results and indicate oxygen flow rate at the time of testing. Supplemental oxygen may be considered when the nocturnal oxygen desaturation is less than 92% for 12% of the night. Testing for nocturnal hypoxemia may be conducted in the community.

Some clients will no longer meet the criteria to continue to receive coverage for oxygen benefits as a result of NIHB Program changes implemented April 1, 2001. Health Canada will inform the prescriber that the patient does not meet the criteria.

If the oxygen system is rented the disposables are automatically included in the price of the rental. If the oxygen system is purchased the disposables may be funded with prior approval and only if they are not included in the maintenance agreement for oxygen system.

Changes to the benefit list include the addition of:

• oxygen cylinder without content, regulator, holder, cart, shoulder pouch and maintenance agreement for purchase of oxygen system
• maintenance agreement, purchase, oxygen system
• Respiratory supplies cool humidifier purchase code and interface with head gear, suction machine rental codes
• tracheostomy supplies and equipment, one of which is distilled water

Pressure Garments

New codes have been added for pressure garments.

Prosthetic Benefits

Pharmacies and MS & E provider can provide knee brace undersleeves, socks and textile sleeves with a medical prescription and prior approval.

While it is recognized that access to a medical specialist may be an issue in some areas, a prescription from a specialist is required for the first issue of a prosthesis. A prescription from a general practitioner will be accepted for a replacement of the same type of prosthesis. Please note, if the replacement is required due to a medical change, loss or irreparable damage and is required before the recommended replacement guideline period, a new prescription from a medical specialist will be required.

Additions to the benefit list include:

Repairs for prosthetic lower limbs has been added Prosthetic supplies list has been expanded Prosthetic replacement guidelines revised The division of Prosthetic Limbs-Lower Extremity into two groups:

Preparatory Prosthesis:

Initial amputees will require more frequent socket changes as residual limb volume may take several months to stabilize. One preparatory socket replacement is allowed within the 12 month period following the date of the initial preparatory socket fitting. Providers should specify "Preparatory prosthesis" on the Prior Approval form. Cosmetic finishing of preparatory devices is not covered.

Definitive Prosthesis:

Once limb volume has stabilized amputees are fit with a definitive prosthesis. The replacement period for a definitive device is three years.