8.0 Respiratory equipment and supplies benefits list

Effective date: February 26, 2024

The following Medical Supplies and Equipment (MS&E) list contains respiratory items and services eligible under the Non-Insured Health Benefits (NIHB) program for eligible First Nations and Inuit. Further you'll find information on coverage policies, item codes, requirements for prior approval and applicable recommended replacement guidelines.

Table of contents

8.1 General information

8.1.1 Benefit policies

General information common to all medical supplies and equipment (MS&E) can be found in the general policies.

8.1.2 Prescriber and provider requirements

Prescriptions or recommendations for coverage must be initiated by the health professionals identified as prescribers or recommenders of the item under the NIHB program. Items that are prescribed by prescribers/recommenders not recognized by NIHB will lead to denials or reversal of claims.

The following is a list of NIHB-recognized prescriber/recommender abbreviations found in this segment of the benefits list. Please refer to the prescriber section of the item tables below to identify the eligible prescriber/recommender of a specific item:

  • INT — Internal Medicine Specialist
  • LPN/RPN – Licensed Practical Nurse/Registered Practical Nurse when within their scope of practice in their province/territory
  • MD — Physician
  • NP — Nurse Practitioner
  • RESP — Respirologist
  • RN — Registered Nurse (renewals only - initial prescription required from MD, NP, NSWOC, WOCC(C))
  • SLP — Speech-Language Pathologist
  • SM — Sleep Medicine Physician

The following is a list of NIHB-recognized provider abbreviations found in this segment of the benefits list. Please refer to the provider section of the item tables below to identify the eligible provider of a specific item:

  • GEN — Enrolled general medical supplies and equipment and pharmacy provider
  • RP — Enrolled respiratory provider with one of the following health care professionals on staff:
    • RRT — Registered Respiratory Therapist
    • RN — Registered Nurse trained in managing respiratory conditions

8.1.3 Prior approval requirements

General prior approval requirements can be found in the general policies.

Prior approval is required for all respiratory equipment and supplies benefits.

To initiate the prior approval process, the Respiratory Prior Approval Form, found on the Express Scripts Canada NIHB provider and client website, must be completed in full and submitted to your NIHB regional office along with the following documentation:

  • required information as described in sections 8.2 to 8.5
  • device make, model, and cost
  • additional relevant information the provider, physician, nurse practitioner or other recognized prescriber/recommender may have to support the request
  • an explanation of benefits from any third-party coverage available to the client (for example, provincial plan, workers' compensation board, private insurance, education plan, etc.)

8.1.4 Exclusions

In addition to the general exclusion policy listed in the general policies, the following items are excluded from the respiratory equipment and supplies benefit and are not considered for coverage or appeal under the NIHB program:

  • respiratory benefits for outings while the client is an in-patient in an acute or long-term hospital setting
  • custom-made masks for ventilation
  • incentive spirometer or volumetric exerciser

8.1.5 Warranties

Provider must honour the manufacturer's warranty.

8.1.6 Repairs

Repairs that are not covered under the warranty are eligible for coverage when supported by proper documentation.

The following rules apply:

  • prior approval is required for repairs
  • request must include detailed cost breakdown of parts, labour time and rates
  • repairs must have a minimum warranty of 90 days

A description of all repairs with dates, detailed cost breakdown of parts, labour time and rates must be kept on file for each client.

Note: The NIHB program will not cover the labour cost for repairs that are covered under the warranty.

8.1.7 Replacement requirements

Recommended replacement guidelines indicate the quantity and frequency at which a benefit item will be eligible for coverage. Recommended replacement guidelines are based on a client's customary medical needs and the typical device's lifespan.

Replacement is subject to the same process as the original purchase.

All replacement requests require a new prescription.

For more general information please see section 1.12 Recommended replacement guidelines.

8.1.7.1 Early replacement requirements

Coverage requests for any early replacement require prior approval, a new prescription as well as documentation supporting the need for early replacement. The client must meet program and equipment-specific eligibility criteria.

Early replacement of items may be considered when one of the following has occurred:

  • there is a substantial change in a client's medical condition (for example, substantial change in weight, etc.) and the item no longer meets the client's needs
  • the item is no longer functioning properly, has deteriorated during typical use and is no longer under warranty (where the cost of repair exceeds the cost of a new item)

The program will not cover the replacement of lost items, stolen items, or items that are damaged due to misuse or negligence.

8.1.8 Services included in the price

The following services must be included in the price of the item to be considered for coverage:

  • product ordering and delivery from manufacturer to provider
  • initial product set-up and mask fitting
  • instruction on the effective use, care and maintenance of the system
  • all ongoing care including follow-up appointments and calls to monitor effectiveness, support compliance and make necessary adjustments (such as mask re-fit)
  • report generation
  • correspondence with NIHB as part of coverage process
  • correspondence with other health care professionals (physician, sleep lab) as necessary

8.1.9 Terminology

Item code

The item code is an 8-digit code that identifies the benefit being requested and is submitted to Express Scripts Canada for billing purposes.

Prior approval

A program coverage confirmation is issued by an NIHB regional office to a provider to ensure that the client is eligible for specific medical supplies and equipment benefits. The approval is issued primarily for items identified as requiring prior approval before being billed to the program. All claims, including claims accompanied by prior approvals, are subject to claim verification.

Recommended replacement guidelines

The recommended replacement guidelines set a maximum number of each item a client may receive over a given period (frequency). Coverage of additional items may be considered on a case-by-case basis. For requests exceeding the recommended replacement guidelines, prior approval is required.

Price guidance

Price guidance may be found in the price files, located on the Express Scripts Canada NIHB provider and client website. Providers are required to justify their costs and submit for reimbursement according to the NIHB claims submission kit.

8.2 PAP (positive airway pressure)

Included in the purchase price:

Included in the rental price:

If the applicant requires the use of oxygen with the rental or purchase of a PAP device, please consult section 5.0 Oxygen equipment and supplies benefits list for more information on the prior approval requirements for oxygen benefits.

8.2.1 CPAP (continuous positive airway pressure)

The program will accept either:

  • a CPAP (or automatic CPAP (APAP)) rental followed by a purchase
    OR
  • an initial request for purchase

8.2.1.1 CPAP rental (up to 3 months)

  • rental may be requested 1 month at a time to:
    • complete PAP titration testing at home
    • demonstrate an improvement in the client's sleep condition
  • an interface and headgear purchase may be covered for the rental period
  • note: the rental fee of the PAP system is to be deducted from the purchase price
Criteria (client must meet A): Required information:
A. diagnosis of obstructive sleep apnea (OSA) with the presence of symptoms.
  • prior approval form including items listed in section 8.1.3 Prior approval requirements
  • clinical information including:
    • age
    • height and weight (Body Mass Index (BMI))
    • Epworth sleepiness scale (ESS)
    • symptoms of sleep-disordered breathing
    • associated risk factors
  • diagnostic sleep study with interpretation by a physician with expertise in sleep medicine
    • accepted sleep studies:
      • level I
      • level III (home sleep study)
      • level IV (overnight oximetry)
    • the apnea-hypopnea index (AHI) must be submitted with the level I and level III sleep study
  • prescription (including pressures)
Note about testing: the NIHB program will consider other testing methods on an exception basis, such as when another diagnostic testing is the accepted testing or standard of care in a given province or territory.

8.2.1.2 CPAP purchase

Purchase may be requested if all the required information is submitted and if there is an improvement in the client's sleep condition (between the diagnostic and treatment sleep study).

Criteria (client must meet A): Required information:
A. diagnosis of obstructive sleep apnea (OSA) with the presence of symptoms.
  • ALL* required information listed under section 8.2.1.1 CPAP rental
    AND
  • the treatment testing while on the PAP system must demonstrate an improvement** in the applicant's sleep condition
* If prescription is for rental, a new prescription for long-term PAP therapy (including pressures) will be required.

** If improvement in the client's condition with the PAP therapy is unclear, the program can request an interpretation from a physician with expertise in sleep medicine and/or summary tracing of the treatment study that confirms requirements.

If the client does not meet all the criteria for purchase, the program may consider rental (please refer to section 8.2.1.1 CPAP rental).
Item code Item name Prescriber* Provider Prior approval required Recommended replacement guidelines Additional details
99400175 CPAP, fixed, purchase INT, MD, NP, RESP, SM RP Yes 1 every 5 years Includes a cleanable/reusable water chamber (not a standard/disposable water chamber)
99400174 CPAP, fixed, rental INT, MD, NP, RESP, SM RP Yes up to 3 months  
99401084 Auto CPAP (APAP), purchase INT, MD, NP, RESP, SM RP Yes 1 every 5 years Includes a cleanable/reusable water chamber (not a standard/disposable water chamber)
99401083 Auto CPAP (APAP), rental INT, MD, NP, RESP, SM RP Yes up to 3 months  
* Registered Respiratory Therapists (RRT) can select and recommend respiratory benefits once the therapy and pressures have been prescribed in provinces and territories where these activities are deemed within their scope of practice, and in accordance with appropriate legislation, regulations, acts or formal governance overseeing the practice. This includes Alberta, Saskatchewan, Manitoba, Ontario, Quebec, Nova Scotia, New Brunswick, Newfoundland and Labrador.

8.2.2 BPAP (bilevel positive airway pressure)

8.2.2.1 BPAP S

Bilevel positive airway pressure with spontaneous breathing (BPAP S) is also referred to as BPAP with no backup rate.

8.2.2.1.1 BPAP S rental (up to 3 months)
Criteria (client must meet ONE): Required information:
  1. diagnosis of OSA and unable to tolerate CPAP pressures
  2. nocturnal saturation of less than 89% despite appropriate CPAP pressures for OSA
  3. nocturnal hypercapnia (PaCO2 greater than 50 mmHg) where the diagnosis of chronic obstructive pulmonary disease (COPD) alone is not the main cause of the hypercapnia despite appropriate CPAP pressures for OSA
  4. AHI is greater than 10 despite appropriate CPAP pressures for OSA
The prescribing physician must have expertise in respiratory medicine.
  • prior approval form including items listed in section 8.1.3 Prior approval requirements
  • prescription (including pressures)
  • diagnostic study:
    • level 1 diagnostic polysomnography with summary tracings and interpretation by a specialist in sleep medicine
      OR
    • level III or IV (oximetry) diagnostic sleep study is accepted if the applicant does not have access to a sleep laboratory. Please include summary tracings and interpretation by a specialist in sleep medicine
8.2.2.1.2 BPAP S purchase
Criteria (client must meet ONE): Required information:
  • ALL required information listed under section 8.2.2.1.1 BPAP S rental
    AND
  • treatment testing while on the PAP system:
    • level I treatment testing polysomnography with summary tracings and interpretation by a specialist in sleep medicine
      OR
    • level III or IV (oximetry) treatment testing is accepted if the applicant does not have access to a sleep laboratory. Please include summary tracings and interpretation by a specialist in sleep medicine

8.2.2.2 BPAP ST

Bilevel positive airway pressure with spontaneous and timed breathing (BPAP ST) is also referred to as BPAP with a backup rate. The device may have additional proprietary ventilation options such as AVAPS.

8.2.2.2.1 BPAP ST rental (up to 3 months)
Criteria (client must meet A or B): Required information:
  1. the applicant has a chronic respiratory failure due to a diagnosis other than COPD, for example, spinal cord injury (SCI)
  2. the applicant has a progressive neuromuscular disease leading to respiratory failure, for example, amyotrophic lateral sclerosis (ALS), muscular dystrophy (MD)
The prescribing physician must have expertise in respiratory medicine.
  • prior approval form including items listed in section 8.1.3 Prior approval requirements
  • physician letter confirming the diagnosis and clinical presentation
  • evidence of diagnostic hypercapnia (for example, arterial blood gas (ABG), capillary blood gas (CBG) or transcutaneous CO2 reading), and nocturnal hypoventilation (oximetry accepted)
  • prescription including pressures and backup rate (BUR)
8.2.2.2.2 BPAP ST purchase
Criteria (client must meet A or B): Required information:
Item code Item name Prescriber* Provider Prior approval required Recommended replacement guidelines Additional details
99400211 BPAP S (Standard or Auto), purchase INT, MD, NP, RESP, SM RP Yes 1 every 5 years  
99400210 BPAP S (Standard or Auto), rental INT, MD, NP, RESP, SM RP Yes up to 3 months  
99400851 BPAP ST (with backup rate), purchase INT, MD, RESP, SM RP Yes 1 every 5 years  
99400850 BPAP ST (with backup rate), rental INT, MD, RESP, SM RP Yes up to 3 months  
* Registered Respiratory Therapists (RRT) can select and recommend respiratory benefits once the therapy and pressures have been prescribed in provinces and territories where these activities are deemed within their scope of practice, and in accordance with appropriate legislation, regulations, acts or formal governance overseeing the practice. This includes Alberta, Saskatchewan, Manitoba, Ontario, Quebec, Nova Scotia, New Brunswick, Newfoundland and Labrador.

8.3 Secretion clearance

8.3.1 Suction machine

  • rental may be requested 1 month at a time (up to 3 months)
  • if suction machine is still required after 3 months, purchase will be considered

Note: the rental fee for the suction machine is to be deducted from the purchase price.

Item code Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400187 Suction machine, purchase INT, MD, NP, RESP, RRT GEN Yes 1 every 5 years  
99400186 Suction machine, rental INT, MD, NP, RESP, RRT GEN Yes    

8.4 Supplies

8.4.1 Supplies for PAP

Item code Item name Prescriber* Provider Prior approval required Recommended replacement guidelines Additional details
99401152 Chin strap Initial request only - INT, MD, NP, RESP, SM RP Yes 2 per year  
99400176 Filters, inlet Initial request only - INT, MD, NP, RESP, SM RP No 14 per year  
99401202 Interface with headgear face Initial request only - INT, MD, NP, RESP, SM RP Yes 2 per year  
99401220 Interface with headgear nasal Initial request only - INT, MD, NP, RESP, SM RP Yes 2 per year  
99401222 Interface headgear nasal pillow Initial request only - INT, MD, NP, RESP, SM RP Yes 2 per year  
99400848 Nasal pillows for headgear Initial request only - INT, MD, NP, RESP, SM RP Yes 2 per year Only to replace nasal pillows of the interface headgear nasal pillow - code 99401222
99401221 Tubing CPAP/BPAP standard Initial request only - INT, MD, NP, RESP, SM RP Yes 2 per year  
* Registered Respiratory Therapists (RRT) can select and recommend respiratory benefits once the therapy and pressures have been prescribed in provinces and territories where these activities are deemed within their scope of practice, and in accordance with appropriate legislation, regulations, acts or formal governance overseeing the practice. This includes Alberta, Saskatchewan, Manitoba, Ontario, Quebec, Nova Scotia, New Brunswick, Newfoundland and Labrador.

8.4.2 Supplies for tracheostomy

Item code Item name Prescriber* Provider Prior approval required Recommended replacement guidelines Additional details
99400626 Distilled water, 4 L container MD, NP, SLP, RN, RRT, (LPN/RPN - renewals only) GEN No 55 per year For tracheostomy care only
99401232 Heat & moisture exchanger (HME), standard MD, NP, SLP, RRT1 GEN No 1 per day  
99401233 Heat & moisture exchanger (HME), specialized MD, NP, SLP, RRT1 GEN No 1 per day  
99401234 Heat & moisture exchanger (HME), housing/baseplate, standard MD, NP, SLP, RRT1 GEN No 1 per day  
99401235 Heat & moisture exchanger (HME), housing/baseplate, specialized MD, NP, SLP, RRT1 GEN No 1 per day  
99400197 Hydrogen peroxide MD, NP, RN, SLP, RRT GEN No 72 per year  
99400198 Pipe cleaner MD, NP, RN, SLP, RRT GEN No 240 per year  
99400193 Speaking valves MD, NP, SLP, RRT GEN Yes 4 per year  
99400201 Tracheostomy brush MD, NP, SLP, RN, RRT, (LPN/RPN - renewals only) GEN No 6 per year  
99400200 Tracheostomy drain sponge MD, NP, RN, SLP, RRT GEN No 800 per year  
99400627 Tracheostomy mask MD, NP, RN, RRT, (LPN/RPN - renewals only) GEN No 24 per year  
99400178 Tracheostomy ties MD, NP, SLP, RN, RRT, (LPN/RPN - renewals only) GEN No 3 rolls/boxes per year Package may include either:
  • 1 roll of single-use twill tape;
    or
  • 1 box of 25 Velcro ties
99400194 Tracheostomy tube MD, NP, SLP, (RRT2 – renewal only) GEN Yes 24 per year Includes the outer cannula with flange (neck plate), the reusable inner cannula, and the obturator
* Registered Respiratory Therapists (RRT) can recommend tracheostomy benefits when within their scope of practice in provinces and territories where these activities are deemed within their scope of practice, and in accordance with appropriate legislation, regulations, acts or formal governance overseeing the practice.

1 – Initial recommendation includes Alberta, Saskatchewan, Manitoba, Ontario, New Brunswick, Newfoundland and Labrador. The program also recognizes RRTs to select HME-related benefits once the therapy has been prescribed. This includes Quebec.

2 – Initial recommendation includes Alberta, Quebec and New Brunswick. The renewal recommendation includes Saskatchewan, Manitoba, Ontario, Nova Scotia, Newfoundland and Labrador.

8.4.3 Supplies for secretion clearance

Item code Item name Prescriber* Provider Prior approval required Recommended replacement guidelines Additional details
99400185 Suction, catheter, disposable MD, NP, RRT, (RN, LPN/RPN - renewals only) GEN Yes 2000 per year  
99400189 Suction, Yankauer, tonsil MD, NP, RRT, (RN, LPN/RPN - renewals only) GEN No 26 per year  
99400188 Tubing and collection bottle MD, NP, RRT, (RN, LPN/RPN - renewals only) GEN No 26 per year  
* Registered Respiratory Therapists (RRT) can select and recommend supplies for secretion clearance in provinces and territories where these activities are deemed within their scope of practice and in accordance with appropriate legislation, regulations, acts or formal governance overseeing the practice. This includes Alberta, Saskatchewan, Manitoba, Ontario, Quebec, Nova Scotia, New Brunswick, Newfoundland and Labrador.

8.5 Servicing

8.5.1 Repairs

Item code Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400195 Repair, respiratory equipment   GEN Yes    

8.5.2 Delivery

Item code Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401265 Delivery, respiratory     Yes   Delivery of equipment to the client

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