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Home > First Nations & Inuit Health > Non-Insured Health Benefits > Health Provider Information > Medical Supplies & Equipment Information > Benefits & Criteria

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First Nations & Inuit Health

3.0 Medical Supplies and Equipment
Orthotics and Custom Footwear Benefits and Criteria

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Orthotics Benefit Categories

Custom Footwear Benefit Categories

See the Orthotics and Custom Footwear 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.

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.

 

3.1 Limb Orthoses - Lower Extremity

Limb Orthoses - Lower Extremity
Item Description Item
Code		 Prior Approval Recommended Replacement Guidelines
Ankle, soft, left 99400574 Yes Soft - Class I 1 year
Ankle, rigid, left 99400575 Yes Rigid - Class II 2 years
Ankle, custom, left 99400576 Yes Custom Class III 2 years
Ankle, soft, right 99400577 Yes Soft - Class I 1 year
Ankle, rigid, right 99400578 Yes Rigid - Class II 2 years
Ankle, custom, right 99400579 Yes Custom Class III 2 years
Ankle foot, soft, left 99400095 Yes Soft - Class I 1 year
Ankle foot, rigid, left 99400096 Yes Rigid - Class II 2 years
Ankle foot, custom, left 99400580 Yes Custom Class III 2 years
Ankle foot, soft, right 99400097 Yes Soft - Class I 1 year
Ankle foot, rigid, right 99400098 Yes Rigid - Class II 2 years
Ankle foot, custom, right 99400581 Yes Custom Class III 2 years
Knee, soft, left 99400099 Yes Soft - Class I 1 year
Knee, rigid, left 99400100 Yes Rigid - Class II 2 years
Knee, custom, left 99400582 Yes Custom Class III 2 years
Knee, soft, right 99400101 Yes Soft - Class I 1 year
Knee, rigid, right 99400102 Yes Rigid - Class II 2 years
Knee, custom, right 99400583 Yes Custom Class III 2 years
Knee ankle foot, rigid, left 99400104 Yes Rigid Class II 2 years
Knee ankle foot, custom, left 99400584 Yes Custom Class III 2 years
Knee ankle foot, rigid, right 99400106 Yes Rigid Class II 2 years
Knee ankle foot, custom, right 99400585 Yes Custom Class III 2 years
Hip knee ankle foot, rigid, left 99400112 Yes Rigid Class II 2 years
Hip knee ankle foot, custom, left 99400586 Yes Custom Class III 2 years
Hip knee ankle foot, rigid, right 99400114 Yes Rigid Class II 2 years
Hip knee ankle foot, custom, right 99400587 Yes Custom Class III 2 years
Hip orthosis, soft, left 99400115 Yes Soft - Class I 1 year
Hip orthosis, rigid, left 99400116 Yes Rigid - Class II 2 years
Hip orthosis, custom, left 99400778 Yes Custom Class III 2 years
Hip orthosis, soft, right 99400117 Yes Soft - Class I 1 year
Hip orthosis, rigid, right 99400118 Yes Rigid - Class II 2 years
Hip orthosis, custom, right 99400779 Yes Custom Class III 2 years
Orthosis for hip dysplasia 99400843 Yes 2 per year
Patella tendon bearing knee, custom, left 99400588 Yes Custom Class III 2 years
Patella tendon bearing knee, custom, right 99400589 Yes Custom Class III 2 years
Thoracic hip knee ankle foot (reciprocating gait mechanism), custom 99400590 Yes Custom Class III 2 years
Repairs - Lower extremity limb orthosis 99400123 Yes  

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3.2 Limb Orthoses - Upper Extremity

Limb Orthoses - Upper Extremity
Item Description Item
Code		 Prior Approval Recommended Replacement Guidelines
Elbow, soft, left 99400124 Yes Soft - Class I 1 year
Elbow, rigid, left 99400125 Yes Rigid - Class II 2 years
Elbow, custom, left 99400592 Yes Custom Class III 2 years
Elbow, soft, right 99400126 Yes Soft - Class I 1 year
Elbow, rigid, right 99400127 Yes Rigid - Class II 2 years
Elbow, custom, right 99400593 Yes Custom Class III 2 years
Finger, single digit, soft, left (specify digit) 99400132 Yes Soft - Class I 1 year
Finger, multiple digits, soft, left (specify digits) 99400594 Yes Soft - Class I 1 year
Finger, single digit, rigid, left (specify digit) 99400133 Yes Rigid - Class II 2 years
Finger, multiple digits, rigid, left (specify digits) 99400595 Yes Rigid - Class II 2 years
Finger, single digit, custom, left 99400596 Yes Custom Class III 2 years
Finger, multiple digits, custom, left 99400597 Yes Custom Class III 2 years
Finger, single digit, soft, right (specify digit) 99400134 Yes Soft - Class I 1 year
Finger, multiple digits, soft, right (specify digits) 99400598 Yes Soft - Class I 1 year
Finger, single digit, rigid, right (specify digit) 99400135 Yes Rigid - Class II 2 years
Finger, multiple digits, rigid, right (specify digits) 99400599 Yes Rigid - Class II 2 years
Finger, single digit, custom, right 99400600 Yes Custom Class III 2 years
Finger, multiple digits custom, right 99400601 Yes Custom Class III 2 years
Shoulder, soft, left 99400602 Yes Soft - Class I 1 year
Shoulder, rigid, left 99400603 Yes Rigid - Class II 2 years
Shoulder, custom, left 99400604 Yes Custom Class III 2 years
Shoulder, soft, right 99400605 Yes Soft - Class I 1 year
Shoulder, rigid, right 99400606 Yes Rigid - Class II 2 years
Shoulder, custom, right 99400607 Yes Custom Class III 2 years
Shoulder elbow, soft, left 99400608 Yes Soft - Class I 1 year
Shoulder elbow, rigid, left 99400609 Yes Rigid - Class II 2 years
Shoulder elbow, custom, left 99400610 Yes Custom Class III 2 years
Shoulder elbow, soft, right 99400611 Yes Soft - Class I 1 year
Shoulder elbow, rigid, right 99400612 Yes Rigid - Class II 2 years
Shoulder elbow, custom, right 99400613 Yes Custom Class III 2 years
Shoulder, elbow, wrist, hand, custom, left 99400591 Yes Custom Class III 2 years
Shoulder, elbow, wrist, hand, custom, right 99400780 Yes Custom Class III 2 years
Wrist hand, soft, left 99400140 Yes Soft - Class I 1 year
Wrist hand, rigid, left 99400141 Yes Rigid - Class II 2 years
Wrist, hand, custom, left 99400614 Yes Custom class III 2 years
Wrist hand, soft, right 99400142 Yes Soft - Class I 1 year
Wrist hand, rigid, right 99400143 Yes Rigid - Class II 2 years
Wrist, hand, custom, right 99400615 Yes Custom class III 2 years
Wrist, hand, finger, soft, left 99400144 Yes Soft Class I 1 year
Wrist hand finger, rigid, left 99400145 Yes Rigid - Class II 2 years
Wrist hand finger, custom, left 99400616 Yes Custom Class III 2 years
Wrist hand finger, soft, right 99400146 Yes Soft - Class I 1 year
Wrist hand finger, rigid, right 99400147 Yes Rigid - Class II 2 years
Wrist hand finger, custom, right 99400617 Yes Custom Class III 2 years
Repairs - Upper extremity limb orthosis 99400148 Yes  

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3.3 Head - Torso - Spine Orthoses

Head -Torso -Spine Orthoses
Item Description Item
Code		 Prior Approval Recommended Replacement Guidelines
Abdominal support 99400149 Yes
1 year
Cervical - soft 99400150 Yes Soft - Class I 1 year
Cervical - rigid 99400151 Yes Rigid - Class II 2 years
Cervical - custom 99400152 Yes Custom-Class III 3 years
Cervical-thoracic-
lumbar-sacral, rigid 		99400618 Yes Rigid - Class II 2 years
Cervical/thoracic/
lumbar/sacral, custom 		99400619 Yes Custom Class III 2 years
Helmet - soft 99400153 Yes Soft - Class I 1 year
Helmet - rigid 99400154 Yes Rigid - Class II 2 years
Helmet - custom 99400155 Yes Custom-Class III 2 years
Hernia truss 99400156 Yes
1 year
Lumbosacral spinal, soft 99400157 Yes Soft - Class I 2 years
Lumbosacral spinal, rigid 99400158 Yes Rigid - Class II 2 years
Lumbosacral spinal, custom 99400159 Yes Custom-Class III 2 years
Pelvic belt 99400162 Yes
1 year
Thoracolumbarsacral, soft 99400163 Yes Soft - Class I 1 year
Thoracolumbarsacral, rigid 99400164 Yes Rigid - Class II 2 years
Thoracolumbarsacral, custom 99400165 Yes Custom-Class III 2 years
Repairs - Head-
Torso-Spine Orthoses 		99400166 Yes  

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3.4 Orthotic Supplies

Orthotic Supplies
Item Description Item
Code		 Prior Approval Recommended Replacement Guidelines
Knee brace undersleeve 99400620 Yes 2 per year
Liner socks for orthotics 99400621 Yes
6 per year
Textile Sleeves 99400622 Yes 2 per year

 

3.5 Custom-Made Shoes

Custom-Made Footwear
Item Description Item
Code		 Prior Approval Recommended Replacement Guidelines
Custom-made shoes 99400167 Yes 1 year
Winter overshoes (only for clients with custom footwear) 99400168 Yes 3 years
Repairs to custom made shoes 99400623 Yes  

 

3.6 Custom-Made Internal Footwear Device

Custom-Made Internal Footwear Device
Item Description Item
Code		 Prior Approval Recommended Replacement Guidelines
Custom-made internal footwear device, left 99400169 Yes 2 years
Custom-made internal footwear device, right 99400170 Yes 2 years
Custom-made internal footwear devices, pair 99400624 Yes 2 years
Custom-made internal footwear devices, repairs 99400781 Yes  

 

3.7 Modifications to Stock Footwear

Modifications to Stock Footwear
Item Description Item
Code		 Prior Approval Recommended Replacement Guidelines
Modifications to stock footwear (this does not include the price of the shoe) 99400171 Yes 2 per 2 year
Repairs to footwear modifications 99400625    
Date Modified: 2010-11-16

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Important Notices