Medical Supplies and Equipment
Respiratory Benefits and Criteria

Respiratory Therapy Benefit Categories:

• Breathing Apparatus and Supplies;
• Respiratory Secretion Clearance; and
• Tracheostomy Supplies and Equipment.

See the Respiratory Benefit List for a full list of eligible products, prior approval requirements and frequency limitations.

Prescriber/Provider Requirements

• Respiratory therapy benefits must be prescribed by a physician.
• Respiratory therapy benefits must be provided by a recognized Medical Supplies and Equipment (MS&E) provider.

Prior Approval Process

A prior approval is required for all respiratory therapy benefits. The provider must contact the First Nations and Inuit Health Branch (FNIHB) Regional Office to initiate the prior approval process.

The Non-Insured Health Benefits (NIHB) Oxygen and Respiratory Program Prior Approval Form (PDF version) must be completed. In addition to the form, this documentation is required to support the request:

• The prescription; and
• CPAP funding requirements.

Consideration for the funding of CPAP units will be given upon receipt of this information:

• Level 1 full baseline and treatment polysomnogragh (PSG) demonstrating diagnosis and response to CPAP or alternative therapy.
  
  
• Clinical information:
  • Age, sex, height and weight, BMI, sleepiness scale (ESS or SSS);
  • Symptoms of sleep disordered breathing and associated risk factors confirmed by the referring physician.

It is recognized that PSG testing may not be readily available in some regions. In such cases, there is a greater need for additional clinical information as outlined below:

• Level 2 sleep study (includes apnea/hypopnea index, saturation, heart rate, body position) with baseline and treatment results obtained during two separate nights or Nocturnal oxygen saturation and heart rate alone with baseline and treatment results obtained during two separate nights.
  
  Clinical information:
  • Age, sex, height and weight, BMI, sleepiness scale (ESS or SSS);
  • Symptoms of sleep disordered breathing and associated risk factors;
  • Evidence that PSG testing was sought including specified waiting period confirmed by the referring physician.
    
    
  Note: Prescriptions for interactive CPAP units will not be accepted without appropriate clinical and objective rationale.
  
  
• Other supporting medical documentation (as required).

If a prior approval is granted, a PA number will be provided for billing purposes. Only then should the provider proceed with the fabrication/ fitting/dispensing of the item. If prior approval is not granted the provider will be advised of the reason.

Note to Ontario Providers: Providers must first contact the Ontario Home Oxygen Program of the Ontario Ministry of Health to access oxygen benefits for Ontario residents.

Exclusions

Exclusions are items that are not listed as benefits under the NIHB Program and are not available through the exception process. These items are therefore not considered for coverage under the NIHB Program and are not subject to the NIHB appeal process. Under the category of Respiratory Therapy Benefits these include, but are not limited to:

• Respiratory equipment for in-patients of an institution;
• Experimental equipment;
• Custom-made mask for ventilation; and
• Incentive spirometer.

Services Included in Price

These services are to be included in the price of the benefit:

• Connectors are provided with tubing; and
• One complete breathing circuit should be included in the initial purchase price of a CPAP, volume ventilator/bi-level unit.

Quantity Limitations

Items that have an annual quantity limitation must be provided and billed for no more than a three-month period at a time. This applies to items claimed with or without a prior approval.

Respiratory Therapy Benefit List

Breathing Apparatus and Supplies

Respiratory Secretion Clearance

Tracheotomy Supplies and Equipment