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7.0 Medical Supplies and Equipment
Respiratory Benefits and Criteria
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Respiratory Supplies and Equipment:
See the Respiratory 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.
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 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.
7.1 Breathing Apparatus and Supplies
Breathing Apparatus and Supplies
| Item Description |
Item
Code |
Prior Approval |
Recommended Replacement Guidelines |
| Breathing circuit tube of CPAP/bi-level |
99400204 |
Yes |
2 per year |
| CPAP circuit, integrated, humidifier, rental |
99400174 |
Yes |
|
| CPAP circuit, integrated, humidifier, purchase |
99400175 |
Yes |
5 years |
| Inlet filters |
99400176 |
No |
12 per year |
| Interface with headgear |
99400180 |
Yes |
2 per year |
| Nasal pillows for headgear |
99400848 |
Yes |
2 per year |
7.2 Respiratory Secretion Clearance
Respiratory Secretion Clearance
| Item Description |
Item
Code |
Prior Approval |
Recommended Replacement Guidelines |
| Suction catheters, disposable |
99400185 |
Yes |
2000 per year |
| Suction machine, rental |
99400186 |
Yes |
|
| Suction machine, purchase |
99400187 |
Yes |
5 years |
| Tubing and collection bottle |
99400188 |
No |
26 per year |
| Yankeur-tonsil suction |
99400189 |
No |
26 per year |
7.3 Tracheotomy Supplies and Equipment
Tracheotomy Supplies and Equipment
| Item Description |
Item
Code |
Prior Approval |
Recommended Replacement Guidelines |
Distilled water
(for tracheostomy care) |
99400626 |
No |
4L containers/55 units per year |
| Heat moisture exchanger |
99400190 |
No |
200 per year |
| Hydrogen Peroxide |
99400197 |
No |
72 bottles per year |
| Pipe cleaners |
99400198 |
No |
240 per year |
| Respiratory equipment, Repairs |
99400195 |
Yes |
|
| Speaking valves |
99400193 |
Yes |
2 per 2 years |
| Tracheostomy brush |
99400201 |
No |
6 per year |
| Tracheostomy drain sponge |
99400200 |
No |
800 per year |
| Tracheostomy mask (Disposables included in the price of oxygen rental
equipment) |
99400627 |
No |
24 per year |
| Tracheostomy ties (Roll) |
99400178 |
No |
2 rolls per year |
| Tracheostomy tubes |
99400194 |
Yes |
24 per year |
(PDF Version - 38 K)
