Medical Supplies and Equipment
Pressure Garments and Pressure Orthotics Benefits and Criteria

Pressure Garments and Pressure Orthotics Benefit Categories:

Lymphedema Compression Device (Orthosis)

• Custom-fitted graduated compression garment;
• Custom-made graduated compression garments;
• Graduated off-the-shelf compression garments; and
• Sequential extremity pump (for primary lymphedema only).

Hypertrophic Scar Management

• Custom-fitted pressure garments;
• Custom-fitted pressure orthosis;
• Custom-made pressure garments;
• Pressure orthosis moulded to client and then custom-fitted to the client; and
• Pressure orthosis moulded to client model and then custom-fitted to the client.

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

Prescriber/Provider Requirements

Pressure garment and pressure orthotics benefits must be prescribed by:

• Burnscar pressure garment, burn orthosis and extremity pump: a physician or medical specialist who is a member of a burn or lymphedema team.

Lymphedema compression garment and/or graduated compression stockings above 40mmHg :

• A vascular surgeon, orthopedic surgeon, radiation oncologist, medical oncologist, internist, pediatrician, plastic surgeon, physiatrist, general surgeon, dermatologist, or thrombologist.

Graduated compression stocking/Sleeve at 20-30, 30-40mmHg:

• A physician.

Pressure garment and pressure orthotics benefits must be provided by:

• A recognized provider who has a vendor certification attesting to expertise in the field, and who holds a certified fitter registration or employs a certified fitter, occupational therapist, physiotherapist or certified prosthetist, orthotist or prosthetist orthotist as certified by the Canadian Board for Certification of Prosthetists and Orthotists (CBCPO).

Prior Approval Process

When a prior approval is required, the provider must contact the FNIHB Regional Office to initiate the process. The Non-Insured Health Benefits Prior Approval Form for Orthotics, Custom Footwear, Prosthetics and Pressure Garments (PDF version) must be completed. In addition to the form, this documentation is required to support the request:

• The prescription; and
• 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.

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 Pressure Garments and Pressure Orthotics, these include, but are not limited to compression stockings for short-term treatment, such as:

• Post-operative surgical stripping;
• Post-operative sclerotherapy; and
• Post-operative edema conditions.

Services Included in Price

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

• Initial assessment to determine type of benefit required;
• Casting of the body part for the manufacturing of the device;
• Manufacturing of device; and
• Dispensing of the benefit, including the adjustment and fitting.

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.

Pressure Garments and Pressure Orthotics Benefit List

Pressure Garments and Pressure Orthoses

Hypertrophic Scar Compression Garment, Custom-made, Custom Fitted, Head

Hypertrophic Scar Compression Garment, Custom-made, Custom Fitted, Limb

Hypertrophic Scar Compression Garment, Custom-made, Custom Fitted, Trunk

Pressure Garments and Pressure Orthoses Accessories