5.0 Medical Supplies and Equipment Pressure Garments and Pressure Orthotics Benefits and Criteria

Pressure Garments and Pressure Orthotics Benefit Categories:

Lymphedema Compression Device (Orthosis)

5.1 Pressure Garments and Pressure Orthoses 5.2 Hypertrophic Scar Compression Garment, Custom-made, Custom Fitted, Head 5.3 Hypertrophic Scar Compression Garment, Custom-made, Custom Fitted, Limb 5.4 Hypertrophic Scar Compression Garment, Custom-made, Custom Fitted, Trunk 5.5 Pressure Garments and Pressure Orthoses Accessories

See the Pressure Garments and Pressure Orthotics Benefit List for a full list of eligible products, prior approval requirements and frequency limitations.

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

Item Description Item Prior Recommended Code Approval Replacement Guidelines Compression glove 20-30/30-40mmHg 99400804 Yes 4 pairs per year Compression /sleeve 20-30, 30- 99400822 Yes 4 pairs per year 40mmHg Compression stocking/sleeve 40mmHg & 99400821 Yes 4 pairs per year up Hi-sustained compression bandage 99400805 Yes 6 per year 35mmHg, reusable, left Hi-sustained compression bandage 99400841 Yes 6 per year 35mmHg, reusable, right Hi-sustained compression bandage 99400839 Yes 24 per year 35mmHg, single use, left Hi-sustained compression bandage 99400840 Yes 24 per year 35mmHg, single use, right Padding single use for reusable Hi- 99400789 Yes 48 per year sustained compression bandage, left and right Stockinette reusable for reusable Hi- 99400842 Yes 12 per year sustained compression bandage 35mmHg, left and right

5.2 Hypertrophic Scar Compression Garment, Custom-made, Custom Fitted, Head

Item Description Item Prior Recommended Code Approval Replacement Guidelines Hypertrophic scar, chin strap 99400057 Yes 2 per 3 months Hypertrophic scar, chin strap, 99400056 Yes 2 per 3 months modified (extended behind the ears) Hypertrophic scar, ear flap attached to 99400062 Yes 2 per 3 months mask or modified chin strap Hypertrophic scar, eye flap attached 99400063 Yes 2 per 3 months to mask Hypertrophic scar, face mask 99400054 Yes 2 per 3 months Hypertrophic scar, face mask, open 99400055 Yes 2 per 3 months face Hypertrophic scar, head band 99400058 Yes 2 per 3 months Hypertrophic scar, lining variation 99400064 Yes 2 per 3 months Hypertrophic scar, lip covering 99400061 Yes 2 per 3 months attached to mask or chin strap Hypertrophic scar, nose covering in 99400060 Yes 2 per 3 months mask Hypertrophic scar, other garment 99400570 Yes 2 per 3 months (provide name of item) Hypertrophic scar, pocket for padding 99400059 Yes 2 per 3 months or splint Hypertrophic scar, trachea opening 99400065 Yes 2 per 3 months

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5.3 Hypertrophic Scar Compression Garment, Custom-made, Custom Fitted, Limb Item Description Item Prior Recommended Code Approval Replacement Guidelines Arm sleeve and gauntlet with enclosed 99400067 Yes 2 per 3 months extended thumb Arm sleeve /gauntlet/shoulder flap 99400068 Yes 2 per 3 months with enclosed extended thumb 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 99400077 Yes 2 per 3 months flap 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 99400066 Yes 2 per 3 months extended thumb Half sleeve with gauntlet metacarpals 99400072 Yes 2 per 3 months to elbow 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

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5.4 Hypertrophic Scar Compression Garment, Custom-made, Custom Fitted, Trunk

Item Description Item Prior Recommended Code Approval Replacement Guidelines Body brief with sleeves 99400087 Yes 2 per 3 months Body brief, sleeveless 99400088 Yes 2 per 3 months Body with sleeves and legs (to 99400089 Yes 2 per 3 months distal measurement above knees) Body suit, sleeveless with legs (to 99400090 Yes 2 per 3 months distal measurement above knees)

5.5 Pressure Garments and Pressure Orthoses Accessories

Item Description Item Prior Recommended Code Approval Replacement Guidelines Sequential extremity pump, 99400091 Yes 5 years purchase Sequential extremity pump, 99400092 Yes rental Sequential Pump accessories, 99400093 Yes 3 years Sequential Pump accessories, 99400094 Yes 3 years sleeves