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5.0 Medical Supplies and Equipment
Pressure Garments and Pressure Orthotics Benefits and Criteria
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Pressure Garments and Pressure Orthotics Benefit Categories:
Lymphedema Compression Device (Orthosis)
See the Pressure Garments and Pressure Orthotics Benefit List for a full
list of eligible products, prior approval requirements and frequency limitations.
For information on policies regarding the provision of orthotics and custom footwear, please consult the Provider Guide for Medical Supplies and Equipment.
Pressure Garments and Pressure Orthotics 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 ESI Canada 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.
5.1 Pressure Garments and Pressure Orthoses
Pressure Garments and Pressure Orthoses
| Item Description |
Item
Code |
Prior Approval |
Recommended Replacement Guidelines |
| Compression glove 20-30/30-40mmHg |
99400804 |
Yes |
4 pairs per year |
| Compression stocking/sleeve 20-30, 30-40mmHg |
99400822 |
Yes |
4 pairs per year |
| Compression stocking/sleeve 40mmHg & up |
99400821 |
Yes |
4 pairs per year |
| Hi-sustained compression bandage 35mmHg, reusable, left |
99400805 |
Yes |
6 per year |
| Hi-sustained compression bandage 35mmHg, reusable, right |
99400841 |
Yes |
6 per year |
| Hi-sustained compression bandage 35mmHg, single use, left |
99400839 |
Yes |
24 per year |
| Hi-sustained compression bandage 35mmHg, single use, right |
99400840 |
Yes |
24 per year |
| Padding single use for reusable Hi-sustained compression bandage, left and right |
99400798 |
Yes |
48 per year |
| Stockinette reusable for reusable Hi-sustained compression bandage
35mmHg, left and right |
99400842 |
Yes |
12 per year |
5.2 Hypertrophic Scar Compression Garment, Custom-made, Custom Fitted, Head
Hypertrophic Scar Compression Garment, Custom-made, Custom Fitted, Head
| Item Description |
Item
Code |
Prior Approval |
Recommended Replacement Guidelines |
| Hypertrophic scar, chin strap |
99400057 |
Yes |
2 per 3 months |
| Hypertrophic scar, chin strap, modified (extended
behind the ears) |
99400056 |
Yes |
2 per 3 months |
| Hypertrophic scar, ear flap attached to mask
or modified chin strap |
99400062 |
Yes |
2 per 3 months |
| Hypertrophic scar, eye flap attached to mask |
99400063 |
Yes |
2 per 3 months |
| Hypertrophic scar, face mask |
99400054 |
Yes |
2 per 3 months |
| Hypertrophic scar, face mask, open face |
99400055 |
Yes |
2 per 3 months |
| Hypertrophic scar, head band |
99400058 |
Yes |
2 per 3 months |
| Hypertrophic scar, lining variation |
99400064 |
Yes |
2 per 3 months |
| Hypertrophic scar, lip covering attached
to mask or chin strap |
99400061 |
Yes |
2 per 3 months |
| Hypertrophic scar, nose covering in mask |
99400060 |
Yes |
2 per 3 months |
| Hypertrophic scar, other garment (provide
name of item) |
99400570 |
Yes |
2 per 3 months |
| Hypertrophic scar, pocket for padding or splint |
99400059 |
Yes |
2 per 3 months |
| Hypertrophic scar, trachea opening |
99400065 |
Yes |
2 per 3 months |
5.3 Hypertrophic Scar Compression Garment, Custom-made, Custom Fitted, Limb
Hypertrophic Scar Compression Garment, Custom-made, Custom Fitted, Limb
| Item Description |
Item
Code |
Prior Approval |
Recommended Replacement Guidelines |
| Arm sleeve and gauntlet with enclosed extended
thumb |
99400067 |
Yes |
2 per 3 months |
| Arm sleeve /gauntlet/shoulder flap with enclosed
extended thumb |
99400068 |
Yes |
2 per 3 months |
| Arm sleeve (wrist to axilla) |
99400074 |
Yes |
2 per 3 months |
| Arm sleeve with attached gauntlet |
99400075 |
Yes |
2 per 3 months |
| Arm sleeve with attached shoulder flap |
99400076 |
Yes |
2 per 3 months |
| Arm sleeve with gauntlet and shoulder flap |
99400077 |
Yes |
2 per 3 months |
| Arm stump to axilla |
99400078 |
Yes |
2 per 3 months |
| Arm stump with shoulder flap |
99400079 |
Yes |
2 per 3 months |
| Elbow band |
99400069 |
Yes |
2 per 3 months |
| Elbow lining (full) |
99400082 |
Yes |
6 per year |
| Elbow lining (inner aspect) |
99400081 |
Yes |
6 per year |
| Foot glove, 2 per limb |
99400571 |
Yes |
2 per 3 months |
| Half sleeve (elbow to axilla) |
99400071 |
Yes |
2 per 3 months |
| Half sleeve (wrist to elbow) |
99400070 |
Yes |
2 per 3 months |
| Half sleeve and gauntlet with enclosed extended
thumb |
99400066 |
Yes |
2 per 3 months |
| Half sleeve with gauntlet metacarpals to elbow |
99400072 |
Yes |
2 per 3 months |
| Half sleeve with shoulder flap |
99400073 |
Yes |
2 per 3 months |
| Hypertrophic scar, anklet |
99400567 |
Yes |
2 per 3 months |
| Hypertrophic scar, chap style, one leg |
99400568 |
Yes |
2 per 3 months |
| Hypertrophic scar, chap style, two legs |
99400569 |
Yes |
2 per 3 months |
| Lining variation |
99400083 |
Yes |
6 per year |
| Pocket for padding or splint |
99400085 |
Yes |
6 per year |
| Reinforced palm on glove or gauntlet |
99400084 |
Yes |
6 per year |
| Shoulder flap, adjustable |
99400086 |
Yes |
6 per year |
| Vest with sleeve |
99400572 |
Yes |
2 per 3 months |
| Vest without sleeve |
99400573 |
Yes |
2 per 3 months |
| Zipper |
99400080 |
Yes |
6 per year |
5.4 Hypertrophic Scar Compression Garment, Custom-made, Custom Fitted, Trunk
Hypertrophic Scar Compression Garment, Custom-made, Custom Fitted, Trunk
| Item Description |
Item
Code |
Prior Approval |
Recommended Replacement Guidelines |
| Body brief with sleeves |
99400087 |
Yes |
2 per 3 months |
| Body brief, sleeveless |
99400088 |
Yes |
2 per 3 months |
| Body suit with sleeves and legs (to distal measurement above knees) |
99400089 |
Yes |
2 per 3 months |
| Body suit, sleeveless with legs (to distal measurement above knees) |
99400090 |
Yes |
2 per 3 months |
5.5 Pressure Garments and Pressure Orthoses Accessories
Pressure Garments and Pressure Orthoses Accessories
| Item Description |
Item
Code |
Prior Approval |
Recommended Replacement Guidelines |
| Sequential extremity pump, purchase |
99400091 |
Yes |
5 years |
| Sequential extremity pump, rental |
99400092 |
Yes |
|
| Sequential Pump accessories, boots |
99400093 |
Yes |
3 years |
| Sequential Pump accessories, sleeves |
99400094 |
Yes |
3 years |
(PDF Version - 65 K)
