3.0 Limb and body orthotics equipment and supplies benefits list (2022)

Effective date: June 22, 2022

On this page

  • 3.1 General information
    • 3.1.1 Benefit policies
    • 3.1.2 Prescriber and provider requirements
    • 3.1.3 Prior approval requirements
      • 3.1.3.1 Off-the-shelf (ClassI)
      • 3.1.3.2 Custom-fitted (ClassII) and custom-made (ClassIII)
    • 3.1.4 Exclusions
    • 3.1.5 Warranties
    • 3.1.6 Repairs
    • 3.1.7 Replacement requirements
    • 3.1.8 Services included in price
    • 3.1.9 Terminology
  • 3.2 Head-torso-spine orthoses
    • 3.2.1 Head and neck
    • 3.2.2 Thoracic
    • 3.2.3 Lumbosacral
    • 3.2.4 Other head-torso-spine orthoses
  • 3.3 Upper extremities
    • 3.3.1 Shoulder
    • 3.3.2 Elbow
    • 3.3.3 Wrist
    • 3.3.4 Finger
  • 3.4 Lower extremities
    • 3.4.1 Hip
    • 3.4.2 Hip-knee-ankle-foot
    • 3.4.3 Knee
    • 3.4.4 Patella
    • 3.4.5 Knee-ankle-foot
    • 3.4.6 Ankle
    • 3.4.7 Ankle foot
    • 3.4.8 Walking boot
  • 3.5 Supplies
  • 3.6 Servicing
    • 3.6.1 Repairs
    • 3.6.2 Delivery

3.1 General information

3.1.1 Benefit policies

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

3.1.2 Prescriber and provider requirements

Prescriptions or recommendations for coverage must be initiated by the health professionals identified as prescribers or recommenders of the specific item as listed in the tables. Items that are prescribed by prescribers/recommenders not recognized by NIHB for the specific item will lead to denials or reversals 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:

  • DPM — Doctor of Podiatric Medicine
  • MD — Physician
  • NP — Nurse Practitioner
  • OT — Occupational Therapist
  • PT — Physiotherapist
  • RN — Registered Nurse
  • RM — Registered Midwife

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 or Pharmacy Provider
  • CO(c) — Certified Orthotist
  • CPO(c) — Certified Prosthetist Orthotist
  • TOP — "Technicien en orthèses et prothèses" certified by the Canadian Board for the Certification of Prosthetists and Orthotists(CBCPO) or by "l'Ordre des technologues professionnels du Québec(OTPQ)" (Quebec only)
  • CHT — Registered occupational therapists and physiotherapists certified by the Hand Therapy Certification Commission, Inc.(HTCC)
  • DPM — Podiatrist (Doctor of Podiatric Medicine)
  • DPodM — Chiropodist registered with provincial or territorial regulatory bodies

3.1.3 Prior Approval Requirements

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

3.1.3.1 Off-the-shelf (Class I)

No prior approval is required for off-the-shelf orthoses that are within the NIHB unit price and recommended replacement guidelines. Prior approval is required for orthoses above the unit price or when the frequency is exceeded. When prior approval is required the provider must submit their actual acquisition cost and mark-up and include explanation and/or documentation supporting the need for a more advanced device.

3.1.3.2 Custom-fitted (Class II) and custom-made (Class III)

Prior approval is required for all custom-fitted and custom-made orthotic devices. To initiate the prior approval process, the Limb and Body Orthotics 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 supporting documentation:

  • the prescription/recommendation or referral form signed by an NIHB recognized prescriber for the requested benefit
  • a detailed physical and biomechanical assessment from the provider describing the clients need for the requested orthosis as well as how the orthosis will address the clients specific physical and/or mobility needs
  • a detailed description of the orthosis being provided. If Custom Fitted Class II – provide manufacture and model number. If custom-made, provide a description of the orthosis, materials and components incorporated
  • information supporting the request such as:
    • detailed description and explanation for any substantial modifications made to an orthosis that impacts the cost of the orthosis. Description to include need for modification, materials used, clinical and technical time/fee involved
    • detailed cost estimate that lists all components and costs (including labour) for complex, unique, multi-component orthosis such as knee-ankle-foot orthosis
  • additional relevant information the provider, physician, podiatrist, nurse practitioner, occupational therapist, or physiotherapist 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.)

3.1.4 Exclusions

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

  • therapy treatment and/or therapy equipment, such as, but not limited to:
    • electrospinal orthosis
    • neurostimulators
    • direct passive movement devices
    • electromagnetic stimulators for osseous growth
  • orthotics that include externally powered or microprocessor components. This exclusion also applies to the replacement of any components, client reimbursement, the coordination of benefits and all repairs for these devices

3.1.5 Warranties

The warranty must include:

  • breakage guarantee for six months on custom-made orthoses
  • no charge for necessary adjustments to a custom-made orthoses for a period of three months after the final fittingFootnote 1
  • breakage guarantee for two months on customized or pre-fabricated orthoses
  • no charge for necessary adjustments to a customized orthosis/pre-fabricated for a period of 30days after the final fittingFootnote 1

3.1.6 Repairs

The program will cover minor repairs to limb and body orthotics under the special authorization process. When providers submit a prior approval for a new orthosis, a special authorization will be created to allow the provider to directly claim up to the posted amounts in the price files for any repair required after the device warranty has expired. The special authorization will be effective from the device warranty expiration date to the device frequency limit. Repair prices are to include materials, components and labour. Special authorizations may also be set up for older orthoses when repairs are requested for the first time.

Before doing any repair, providers should confirm with Express Scripts Canada if prior approval is required. Repairs that are not covered under the warranty are eligible for coverage when supported by proper documentation.

The following rules apply:

  • warranty is expired
  • repairs must have a minimum warranty of 90days
  • request must include detailed cost breakdown of materials, components, labour time and rates
  • prior approval is required for repairs exceeding the recommended frequency or unit price

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

Providers may submit a request for prior approval at any time for repairs that may be required over the frequency guideline or posted price.

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

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3.1.7 Replacement requirements

An original prescription may be used for a replacement request when submitted by the same provider if:

  • limb and body orthotic was initially covered by the NIHB program
  • item requested addresses the same medical condition as the original item
  • the client's functional status remains unchanged
  • the replacement is within the recommended replacement guideline

All other requests for replacement require a new prescription. If an item is required before the recommended replacement guidelines, documentation supporting the need for early replacement must be provided.

A copy of the prescription and prescriber number must be kept in the clients file at the provider's office with all orthotic replacements.

3.1.8 Services included in the price

The following services are to be included in the price of the item:

  • initial assessment to determine the type of benefit required
  • product and material/componentry ordering and delivery from manufacturer to provider (including delivery costs, exchange rate)
  • shape/volume capture of the body part for the manufacturing of the device
  • manufacturing/fabricating of the device
  • dispensing of the benefit, which includes the adjustment, fitting
  • follow-up visit(s)

3.1.9 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 a 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.

Recommended replacement guidelines

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

Unit price

Unit price information may be found on the price files, located on the Express Scripts Canada NIHB provider and client website.

Limb and body orthotic classes are defined as:

Off-the-shelf (Class I):
Off-the-shelf or class I orthosis are orthoses that a client can purchase and fit themselves, including items that are typically purchased at a pharmacy. Off-the-shelf orthoses requires minimal assessment and fitting skill. Additionally, any adjustments required to modify or fit the orthosis can be done by hand – for example, bending a metal stay to contour for a better fit to the limb. These products are standard sizes (small, medium, large) or from a sizing chart and may be provided by an NIHB enrolled general medical supplies and equipment or pharmacy provider. Please note, if a manufacturer has a "custom" option for an orthosis that would typically be classified as an off-the-shelf orthosis, such as a neoprene knee sleeve that is custom made to a client's specific measurements, it would still be classified as class I.

Custom-fitted (Class II):
A custom-fitted or class II orthosis is more complex than a class I item. Class II items require expertise to either assess or fit the orthosis. For example, the client may have a condition that requires more in depth assessment and/or follow-up such as wound care in diabetic clients. Custom-fit or class II orthosis may require more significant alteration to fit the client, including the use of heat or tools. The item may be selected from a wide range of stock, and be referred to as 'off-the-shelf' however; expertise is required to select the orthosis that would best meet the client's needs. For example, class II off-the-shelf knee orthosis requires very little customizing due to the way the brace is fabricated, however expertise is required to ensure that the brace is suitable for the client and to ensure the forces applied by the orthosis to the knee are appropriate for the condition such as unloading forces in a Osteoarthritis unloading knee brace. Additionally, improperly fitting items could cause more serious health problems such as skin breakdown or aggravating joint/ligament issues. For this reason, NIHB eligible providers of class II braces must be certified Orthotists or certified Prosthetist Orthotists. Certified Hand Therapists certified by the Hand Therapy Certification Commission, Inc. (HTCC) are NIHB eligible providers for upper extremity orthoses only.

Custom-made (Class III):
A custom-made or class III orthosis is assessed for, designed, and fabricated based on an individual client measurements using a cast or digital shape and volume capture methods. NIHB eligible providers of these items are certified Orthotists or certified Prosthetist Orthotists. Certified Hand Therapists certified by the Hand Therapy Certification Commission, Inc. (HTCC) are NIHB eligible providers for upper extremity orthoses only.

3.2 Head-torso-spine orthoses

3.2.1 Head and neck

Item numberItem namePrescriberProviderPrior approval requiredRecommended replacement guidelinesAdditional details
99400151Cervical, custom-fittedMD, NP, PTCO(c), CPO(c), TOPYes1 every 2 years
99400152Cervical, custom-madeMD, NPCO(c), CPO(c), TOPYes1 every 2 years
99400150Cervical, off-the-shelfMD, NP, PTGENNo1 per year
99400154Helmet, custom-fittedMD, NP, OT, PTCO(c), CPO(c), TOPYes1 every 2 years
99400155Helmet, custom-madeMD, NPCO(c), CPO(c), TOPYes1 every 2 years
99400153Helmet, off-the-shelfMD, NP, OT, PTGENNo1 per year

3.2.2 Thoracic

Item numberItem namePrescriberProviderPrior approval requiredRecommended replacement guidelinesAdditional details
99400590Thoracic, hip-knee-ankle-foot, custom-madeMD, NPCO(c), CPO(c), TOPYes1 every 2 yearsReciprocating gait mechanism
99400164Thoracolumbarsacral, custom fittedMD, NPCO(c), CPO(c), TOPYes1 every 2 yearsProvide date of fracture and surgery as applicable
99400165Thoracolumbarsacral, custom-madeMD, NPCO(c), CPO(c), TOPYes1 every 2 yearsProvide date of fracture and surgery as applicable
99400163Thoracolumbarsacral, off-the-shelfMD, NP, PTGENNo1 per year
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3.2.3 Lumbosacral

Item numberItem namePrescriberProviderPrior approval requiredRecommended replacement guidelinesAdditional details
99400158Lumbosacral spinal, custom-fittedMD, NP, PTCO(c), CPO(c), TOPYes1 every 2 years
99400159Lumbosacral spinal, custom-madeMD, NPCO(c), CPO(c), TOPYes1 every 2 years
99400157Lumbosacral spinal, off-the-shelfMD, NP, PTGENNo1 per year

3.2.4 Other head-torso-spine orthoses

Item numberItem namePrescriberProviderPrior approval requiredRecommended replacement guidelinesAdditional details
99400149Abdominal supportMD, NP, OT, PT, RNGENNo1 per year
99400619Cervical-thoracic-lumbar-sacral, custom-madeMD, NPCO(c), CPO(c), TOPYes1 every 2 years
99400618Cervical-thoracic-lumbar-sacral, custom fittedMD, NPCO(c), CPO(c), TOPYes1 every 2 years
99400156Hernia trussMD, NPGENNo1 per year
99400933Maternity beltMD, NP, PT, RM, RNGENNo1 per pregnancy
99400162Pelvic beltMD, NP, PTGENNo1 per year

3.3 Upper extremities

3.3.1 Shoulder

Item numberItem namePrescriberProviderPrior approval requiredRecommended replacement guidelinesAdditional details
99400603Shoulder, custom-fitted, leftMD, NP, PTCO(C), CPO(C), TOPYes1 every 2 years
99400606Shoulder, custom-fitted, rightMD, NP, PTCO(c), CPO(c), TOPYes1 every 2 years
99400604Shoulder, custom-made, leftMD, NPCO(c), CPO(c), TOPYes1 every 2 years
99400607Shoulder, custom-made, rightMD, NPCO(c), CPO(c), TOPYes1 every 2 years
99400602Shoulder, off-the-shelf, leftMD, NP, PTGENNo1 per year
99400605Shoulder, off-the-shelf, rightMD, NP, PTGENNo1 per year
99400609Shoulder-elbow, custom-fitted, leftMD, NP, PTCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400612Shoulder-elbow custom-fitted, rightMD, NP, PTCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400610Shoulder-elbow, custom-made, leftMD, NPCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400613Shoulder-elbow, custom-made, rightMD, NPCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400608Shoulder-elbow, off-the-shelf, leftMD, NP, PTGENNo1 per year
99400611Shoulder-elbow, off-the-shelf, rightMD, NP, PTGENNo1 per year
99400591Shoulder-elbow-wrist-hand, custom-made, leftMD, NPCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400780Shoulder-elbow-wrist-hand, custom-made, rightMD, NPCO(C), CPO(C), TOP, CHTYes1 every 2 years

3.3.2 Elbow

Item numberItem namePrescriberProviderPrior approval requiredRecommended replacement guidelinesAdditional details
99400125Elbow, custom-fitted, leftMD, NP, PTCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400127Elbow, custom-fitted, rightMD, NP, PTCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400592Elbow, custom-made, leftMD, NPCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400593Elbow, custom-made, rightMD, NPCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400124Elbow, off-the-shelf, leftMD, NP, PTGENNo1 per year
99400126Elbow, off-the-shelf, rightMD, NP, PTGENNo1 per year

3.3.3 Wrist

Item numberItem namePrescriberProviderPrior approval requiredRecommended replacement guidelinesAdditional details
99400141Wrist-hand, custom-fitted, leftMD, NP, OT, PTCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400143Wrist-hand, custom-fitted, rightMD, NP, OT, PTCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400614Wrist-hand, custom-made, leftMD, NPCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400615Wrist-hand, custom-made, rightMD, NPCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400140Wrist-hand, off-the-shelf, leftMD, NP, OT, PTGENNo1 per year
99400142Wrist-hand, off-the-shelf, rightMD, NP, OT, PTGENNo1 per year
99400145Wrist-hand-finger, custom-fitted, leftMD, NP, OT, PTCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400147Wrist-hand-finger, custom-fitted, rightMD, NP, OT, PTCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400616Wrist-hand-finger, custom-made, leftMD, NPCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400617Wrist-hand-finger, custom-made, rightMD, NPCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400144Wrist-hand-finger, off-the-shelf, leftMD, NP, OT, PTGENNo1 per year
99400146Wrist-hand-finger, off-the-shelf, rightMD, NP, OT, PTGENNo1 per year

3.3.4 Finger

Specify which digits within prior approval request.

Item numberItem namePrescriberProviderPrior approval requiredRecommended replacement guidelinesAdditional details
99400595Finger, multiple digits, custom-fitted, leftMD, NP, OT, PTCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400599Finger, multiple digits, custom-fitted, rightMD, NP, OT, PTCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400597Finger, multiple digits, custom-made, leftMD, NPCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400601Finger, multiple digits, custom-made, rightMD, NPCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400594Finger, multiple digits, off-the-shelf, leftMD, NP, OT, PTGENNo1 per year
99400598Finger, multiple digits, off-the-shelf, rightMD, NP, OT, PTGENNo1 per year
99400133Finger, single digit, custom-fitted, leftMD, NP, OT, PTCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400135Finger, single digit, custom-fitted, rightMD, NP, OT, PTCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400596Finger, single digit, custom-made, leftMD, NPCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400600Finger, single digit, custom-made, rightMD, NPCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400132Finger, single digit, off-the-shelf, leftMD, NP, OT, PTGENNo1 per year
99400134Finger, single digit, off-the-shelf, rightMD, NP, OT, PTGENNo1 per year
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3.4 Lower extremities

3.4.1 Hip

Item numberItem namePrescriberProviderPrior approval requiredRecommended replacement guidelinesAdditional details
99400116Hip orthosis, custom-fitted, leftMD, NP, PTCO(C), CPO(C), TOPYes1 every 2 years
99400118Hip orthosis, custom-fitted, rightMD, NP, PTCO(C), CPO(C), TOPYes1 every 2 years
99400778Hip orthosis, custom-made, leftMD, NPCO(C), CPO(C), TOPYes1 every 2 years
99400779Hip orthosis, custom-made, rightMD, NPCO(C), CPO(C), TOPYes1 every 2 years
99400115Hip orthosis, off-the-shelf, leftMD, NP, PTGENYes1 per year
99400117Hip orthosis, off-the-shelf, rightMD, NP, PTGENYes1 per year
99400843Orthosis for hip dysplasiaMD, NP, PTCO(C), CPO(C), TOPYes2 per year

3.4.2 Hip-knee-ankle-foot

Item numberItem namePrescriberProviderPrior approval requiredRecommended replacement guidelinesAdditional details
99400112Hip-knee-ankle-foot, custom-fitted, leftMD, NP, PTCO(C), CPO(C), TOPYes1 every 2 years
99400114Hip-knee-ankle-foot, custom-fitted, rightMD, NP, PTCO(C), CPO(C), TOPYes1 every 2 years
99400586Hip-knee-ankle-foot, custom-made, leftMD, NPCO(C), CPO(C), TOPYes1 every 2 years
99400587Hip-knee-ankle-foot, custom-made, rightMD, NPCO(C), CPO(C), TOPYes1 every 2 years

3.4.3 Knee

Item numberItem namePrescriberProviderPrior approval requiredRecommended replacement guidelinesAdditional details
99400100Knee, custom-fitted, leftMD, NP, PTCO(C), CPO(C), TOPYes1 every 2 years
99400102Knee, custom-fitted, rightMD, NP, PTCO(C), CPO(C), TOPYes1 every 2 years
99400582Knee, custom-made, leftMD, NPCO(C), CPO(C), TOPYes1 every 2 years
99400583Knee, custom-made, rightMD, NPCO(C), CPO(C), TOPYes1 every 2 years
99400099Knee, off-the-shelf, leftMD, NP, PTGENNo1 per year
99400101Knee, off-the-shelf, rightMD, NP, PTGENNo1 per year

3.4.4 Patella

Item numberItem namePrescriberProviderPrior approval requiredRecommended replacement guidelinesAdditional details
99400588Patella tendon bearing, knee, custom-made, leftMD, NPCO(C), CPO(C), TOPYes1 every 2 years
99400589Patella tendon bearing, knee, custom-made, rightMD, NPCO(C), CPO(C), TOPYes1 every 2 years

3.4.5 Knee-ankle-foot

Item numberItem namePrescriberProviderPrior approval requiredRecommended replacement guidelinesAdditional details
99400104Knee-ankle-foot, custom-fitted, leftMD, NP, PTCO(C), CPO(C), TOPYes1 every 2 years
99400106Knee-ankle-foot, custom-fitted, rightMD, NP, PTCO(C), CPO(C), TOPYes1 every 2 years
99400584Knee-ankle-foot, custom-made, leftMD, NPCO(C), CPO(C), TOPYes1 every 2 years
99400585Knee-ankle-foot, custom-made, rightMD, NPCO(C), CPO(C), TOPYes1 every 2 years
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3.4.6 Ankle

Item numberItem namePrescriberProviderPrior approval requiredRecommended replacement guidelinesAdditional details
99400575Ankle, custom-fitted, leftMD, NP, PTCO(C), CPO(C), TOPYes1 every 2 years
99400578Ankle, custom-fitted, rightMD, NP, PTCO(C), CPO(C), TOPYes1 every 2 years
99400576Ankle, custom-made, leftMD, NPCO(C), CPO(C), TOPYes1 every 2 years
99400579Ankle, custom-made, rightMD, NPCO(C), CPO(C), TOPYes1 every 2 years
99400574Ankle, off-the-shelf, leftMD, NP, PTGENNo1 per year
99400577Ankle, off-the-shelf, rightMD, NP, PTGENNo1 per year

3.4.7 Ankle foot

Item numberItem namePrescriberProviderPrior approval requiredRecommended replacement guidelinesAdditional details
99400096Ankle-foot, custom-fitted, leftMD, NP, PTCO(C), CPO(C), TOPYes1 every 2 years
99400098Ankle-foot, custom-fitted, rightMD, NP, PTCO(C), CPO(C), TOPYes1 every 2 years
99400580Ankle-foot, custom-made, leftMD, NPCO(C), CPO(C), TOPYes1 every 2 years
99400581Ankle-foot, custom-made, rightMD, NPCO(C), CPO(C), TOPYes1 every 2 years
99400095Ankle-foot, off-the-shelf, leftMD, NP, PTGENNo1 per year
99400097Ankle-foot, off-the-shelf, rightMD, NP, PTGENNo1 per year
99400847Club foot orthosis replacement barDPM, MD, NPCO(C), CPO(C), TOP, DPM, DPODMYes1 per year
99400845Club foot orthosis replacement boot – for children under 1 year oldDPM, MD, NPCO(C), CPO(C), TOP, DPM, DPODMYes2 per year
99400846Club foot orthosis replacement boot - for children over 1 year oldDPM, MD, NPCO(C), CPO(C), TOP, DPM, DPODMYes1 per year
99400844Orthosis for club footDPM, MD, NPCO(C), CPO(C), TOP, DPM, DPODMYes1 per year

3.4.8 Walking boot

Item numberItem namePrescriberProviderPrior approval requiredRecommended replacement guidelinesAdditional details
99400808Foot bed liner, custom-madeDPM, MD, NP, PTCO(C), CPO(C), TOP, DPM, DPODMYes1 per yearTo be used with code 99400807 offloading diabetic walking boot
99400807Offloading diabetic walking bootDPM, MD, NP, PTCO(C), CPO(C), TOP, DPM, DPODMYes1 per yearCoverage for an offloading diabetic boot is provided for clients with pressure ulcer(s) on the plantar (bottom) of the foot.
99401183Offloading walking bootDPM, MD, NP, PTGENYes1 per yearCoverage is provided for a client that requires an offloading walking boot due to a medical condition for which the walking boot was deemed to be the optimum treatment after considering all factors, including reasonable access to medical treatment.

3.5 Supplies

Item numberItem namePrescriberProviderPrior approval requiredRecommended replacement guidelinesAdditional details
99400620Knee brace undersleeveMD, NP, PTGENYes2 per year
99400621Liner socks for orthoticsMD, NPGENYes6 per year
99400622Textile interface garmentMD, NPGENYes2 per year

3.6 Servicing

3.6.1 Repairs

Item numberItem namePrescriberProviderPrior approval requiredRecommended replacement guidelinesAdditional details
99400945Repair, lower extremity limb orthosis, leftCO(C), CPO(C), TOPYes1 per year
99400123Repair, lower extremity limb orthosis, rightCO(C), CPO(C), TOPYes1 per year
99400166Repair, head-torso-spine orthosisCO(C), CPO(C), TOPYes1 per year
99400148Repair, upper extremity limb orthosis, rightCO(C), CPO(C), TOP, CHTYes1 every 2 years
99400946Repair, upper extremity limb orthosis, leftCO(C), CPO(C), TOP, CHTYes1 every 2 years

3.6.2 Delivery

Item numberItem namePrescriberProviderPrior approval requiredRecommended replacement guidelinesAdditional details
99401261Delivery, limb and body orthoticsYes
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