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
List Terminology
- Item Description:
- Items are listed within general and specific categories (for example:
Audiology), in alphabetical order by category and item.
- Item Code:
- The 8-digit code that must be submitted to First Canadian Health
for billing purposes.
- Prior Approval:
- Identifies by general category, or by item within the category,
whether prior approval must be obtained by the provider before dispensing
the item.
Breathing Apparatus and Supplies
Item Description |
Item
Code |
Prior Approval |
Recommended Replacement Guidelines |
Breathing circuit, CPAP, purchase |
|
Yes |
2 per year |
CPAP cool humidifier, purchase |
|
Yes |
5 years |
CPAP with complete circuit/cool humidifier, rental |
|
Yes |
|
CPAP with complete circuit/cool humidifier, purchase |
|
Yes |
5 years |
Inlet filters |
|
No |
12 per year |
Interface with headgear |
|
Yes |
2 per year |
Respiratory Secretion Clearance
Item Description |
Item
Code |
Prior Approval |
Recommended Replacement Guidelines |
Suction catheters, disposable |
|
No |
2000 per year |
Suction machine, rental |
|
Yes |
|
Suction machine, purchase |
|
Yes |
5 years |
Tubing and collection bottle |
|
No |
26 per year |
Yankeur-tonsil suction |
|
No |
26 per year |
Tracheotomy Supplies and Equipment
Item Description |
Item
Code |
Prior Approval |
Recommended Replacement Guidelines |
Distilled water
(for tracheostomy care) |
|
No |
4L containers/55 units per year |
Heat moisture exchanger |
|
No |
200 per year |
Hydrogen Peroxide |
|
No |
72 bottles per year |
Pipe cleaners |
|
No |
240 per year |
Normal saline (3ml units) |
|
No |
1000 per year |
Speaking valves |
|
Yes |
2 years |
Tracheostomy brush |
|
No |
6 per year |
Tracheostomy drain sponge |
|
No |
800 per year |
Tracheostomy mask (Disposables included in the price of oxygen rental
equipment) |
|
No |
24 per year |
Tracheostomy ties (Roll) |
|
No |
2 rolls per year |
Tracheostomy tubes |
|
Yes |
24 per year |
Respiratory equipment, Repairs |
|
Yes |
|
|