13.0 Medical surgical equipment and supplies benefits list

13.1.1 Benefit policies

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

13.1.2 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 or recommenders not recognized by NIHB will lead to denials or reversal of claims.

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

• LPN/RPN — Licensed Practical Nurse or Registered Practical Nurse when within their scope of practice in their province or territory, renewals only
• MD — Physician
• NP — Nurse Practitioner
• NSWOC — Nurse Specialized in Wound, Ostomy and Continence
• RN renewals only — Registered Nurse, initial prescription required from MD, NP, NSWOC, WOCC(C)
• OT — Occupational Therapist
• PT — Physiotherapist
• RM — Registered Midwife
• RN — Registered Nurse
• WOCC(C) — Wound, Ostomy and Continence Certified (C)anada

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

• GEN — Enrolled general MS&E or pharmacy provider
• GEN-CCGF — Enrolled general MS&E or pharmacy provider with staff certified as a compression garment fitter

13.1.3 Prior approval requirements

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

To initiate the prior approval process, the Medical Surgical 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 or recommendation or referral form signed by an NIHB-recognized prescriber for the requested benefit
• item information: manufacturer name, manufacturer model or SKU number, full item name, size, if applicable, quantity, and start and end dates
• detailed assessment as required
• additional relevant information the provider, physician, 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.

13.1.4 Exclusions

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

• environmental protection devices and supplies, for example, air cleaners, filters, UV protection garments and lotions, etc.

13.1.5 Warranties

Providers must honour the manufacturer's warranty.

13.1.6 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 exceeding the NIHB price or frequency
• 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.

13.1.7 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, see section 1.12 Recommended replacement guidelines.

13.1.8 Services included in the NIHB price

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

• initial assessment to determine the type of benefit required
• dispensing of the item, including necessary adjustments, setup and installation
• follow-ups: all ongoing care including follow-up assessments, telephone calls and correspondence
• client education and instructions on the effective use, safety, and care of the equipment and supplies

13.1.9 Terminology

13.2.1 Diapers and liners

The following information is required when requesting coverage for diapers and liners:

• prior approval form including items listed in section 13.1.3 Prior approval requirements
• medical diagnosis that is the causes of the incontinence
• type of incontinence, bladder, bowel, or both
• when the incontinence occurs day or night
• type of incontinence supplies needed
• size of the incontinence supplies requested, does not apply to children's sizes or liners
• quantity of incontinence supplies needed
• other supporting information, for example, temporary or permanent condition

If there is a substantial change in the client's condition requiring a variation in frequency or a change in requested supplies, a new incontinence assessment should be submitted.

13.2.2 Underpads

The following information is required when requesting coverage for underpads:

• prior approval form including items listed in section 13.1.3 Prior approval requirements
• type of incontinence supplies needed, washable or disposable underpads
• size of the incontinence supplies requested
• quantity of incontinence supplies needed
• incontinence only:
  • medical diagnosis that is the causes of the incontinence
  • type of incontinence, bladder, bowel, or both
  • when the incontinence occurs day or night
  • other supporting information, for example, temporary or permanent condition
• ostomy only:
  • medical diagnosis or type of ostomy, for example, colostomy, ileostomy, urostomy
  • other supporting information, for example, temporary or permanent condition
• wound care only:
  • diagnosis, wound type
  • wound location and wound size
  • other supporting information, for example, frequency of dressing change per wound, wound irrigation needs

If there is a substantial change in the client's condition requiring a variation in frequency or a change in requested supplies, a new incontinence or ostomy assessment should be submitted.

13.2.3 Catheters

13.2.4 Devices

13.3.1 One-piece pouch

13.3.2 Two-piece pouch

13.3.3 Ostomy supplies

Open benefit quantities

Clients are eligible for a number of dressings as open benefit. The open benefit quantity applies to all dressing sizes that have their own specific benefit code. The dressing codes called other sizes, found in each dressing category, cannot be claimed as an open benefit. However, the quantity of dressings requested against the other sizes code is counted in the open benefit quantity limit.

Open benefit quantities are set to provide immediate same-day access to supplies when wound care is started, for example, a client is discharged home from the hospital with a wound, or a client has a new wound. These open benefit quantities should provide most clients up to 4 weeks of wound care supplies. This allows time to start the prior approval process:

• the health professional completes a wound assessment and submits it to the client's provider of choice
• the provider completes the prior approval form and submits the required documents to the client's NIHB regional office
• the program reviews client and item eligibility and communicates the coverage decision to the provider

Providers are encourage to claim open benefits through their ESC Web Account to facilitate processes. For more information, consult the MS&E Claims Submission Kit available on the Express Scripts Canada NIHB provider and client website or contact the NIHB Call Centre at Express Scripts Canada directly.

Note: if the dressing size required to start wound care does not have a specific benefit code, it does not have an open benefit quantity, the request can be submitted as urgent to ensure timely access to care. The reason for the urgency must be indicated on the prior approval form.

Limited use quantities

Once the open benefit quantity is exceeded, the client is still eligible for wound care supplies. When this happens, the benefit codes are simply considered as limited use instead of open benefit.

Limited use items require a prior approval from the NIHB regional office. For coverage consideration, a wound assessment must be submitted along with a prior approval form including the items listed in section 13.1.3 Prior approval requirements.

To determine the eligible quantities of limited use items, the following information must be submitted with the prior approval form:

• quantity of dressing(s) required
• frequency of dressing change
• and the coverage period: start and end dates

If the requested quantity is larger than the frequency of dressing changes multiplied by the coverage period, an explanation supporting this need will be requested. If a higher quantity is required, please submit a justification with the request to prevent coverage delays.

Wound assessment

A new wound assessment is required with every request. The same wound assessment cannot be used for 2 different coverage periods. When completed and signed by an NIHB-recognized prescriber or recommender, the wound assessment can be used as the prescription or recommendation.

The NIHB Wound Assessment Form available on the Express Scripts Canada NIHB provider and client website, includes all the required information needed to review coverage eligibility. This form is not mandatory but the following information is required for coverage consideration:

• a description of each wound:
  • date of wound onset
  • exudate amount: nil or none, scant or small, moderate, large, or unable to assess
  • exudate type: nil or none, sanguinous, serous, serosanguinous, purulent, or unable to assess
  • wound diagnosis, for example, pressure ulcer, venous ulcer, surgical incision, burn, etc.
  • wound location
  • wound size: length x width x depth, in cm or mm
  • wound tunneling: direction and depth
  • wound type: acute or chronic
• a description of the wound care treatment (care plan) for each wound:
  • conservative sharp wound debridement details and frequency, if applicable
  • coverage period
  • frequency of dressing changes, for example, daily, every 2 days, weekly, etc.
  • type and size of dressings requested
  • quantity of dressings required per dressing change
  • note: to prevent delays in review, clinicians must clearly indicate which dressing(s) will be:
    • used with which wound
    • in contact with the wound: primary dressing
    • a cover dressing, secondary dressing, if required

Any other additional information to support the review may be submitted or requested by the NIHB program if deemed necessary:

• exposed tissue or structure, for example, bone, fascia, ligament, muscle, tendon, or medical device
• important associated conditions, for example, infection status, irrigation needs, antibiotics, chemotherapy, etc.
• odour, for example, none, faint, moderate, strong
• periwound skin, for example, intact, erythema, indurated, macerated, excoriated, callused, fragile, etc.
• wound bed information, for example, percentage of granulation, slough, and eschar tissues

The required wound assessment information may be submitted in another format. If using a different form or format then the NIHB Wound Assessment Form, clinicians must make sure that the required information is submitted to prevent delays in review.

Coverage periods

There are 3 different coverage periods for wound care that applies to all wound diagnoses:

• acute wounds: 30 days
  • a wound that has been present for less than 8 weeks or that is healing is considered acute
  • wound care supplies for acute wounds can be submitted for 1 month (30 days) at a time
• chronic wounds: 90 days
  • a wound that has been present for 8 or more weeks and is not healing in the ordered repair stages is considered chronic
  • wound care supplies for a chronic wound can be submitted for 3 months (90 days) at a time
• palliative care clients: 90 days
  • the client must have been diagnosed with a terminal illness or disease which is expected to be the primary cause of death within 6 months or less
  • wound care supplies for a palliative client can be submitted for 3 months (90 days) at a time

A new wound assessment is required with every request. If there is no information to support that a client has a chronic wound or is palliative, the request will be considered for 30 days instead of 90 days to prevent delays.

Classification

The following information is required to determine classification:

• manufacturer name
• manufacturer model or SKU number
• full item name
• dressing size
• wound size

How to correctly classify a dressing to determine eligible frequency and NIHB price:

1. Identify the dressing category
   • dressings are classified first based on their composition. Use the dressing category definitions and look through the lists of dressing brand examples^{Footnote 1} to help determine the dressing category, for example, composite, honey, silver, etc.
2. Identify the benefit code
   • within their respective category, dressings are then classified by their size to identify the correct benefit code
   • compare the size of the dressing with the existing benefit code sizes within the identified category
     • if the dressing is within 0.5 cm or 1 g size difference of a specific code, use this code to classify the dressing
     • if the dressing is not within 0.5 cm or 1 g difference of a specific code, use the code called "other sizes"

Once the benefit code is identified, the size of the dressing will be compared to the size of the wound. If the requested dressing size is much larger than the wound size, additional information will be requested. If the dressing will be cut, please indicate into how many dressings or to which size the dressing will be cut, to prevent delays.

Wound care items not currently listed

Items that are not currently listed in the NIHB MS&E Guide and Benefit Lists for First Nations and Inuit may be considered as exceptions. Coverage may be provided on a case-by-case basis for items not listed under exclusions. Prior approval must be requested from the NIHB regional office and a written medical justification must accompany the request.

Please note that alcohol prep pads, iodine prep pads, and iodine cleansing solution are not MS&E benefits. Requests for these items should be submitted to the NIHB Pharmacy benefit.

13.4.1 Adhesives

Supplies in this category are used to provide support and retain contact with the body over a length of time. They can be used to secure dressings and other medical devices.

NIHB does not cover any specific brand of dressing and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

13.4.2 Alginates/hydrofibres/poly-absorbent fibres dressings

Dressings in this category are composed of different absorbent textiles such as alginate, hydrofibres, or poly-absorbent fibres. These dressings typically produce a gel-like substance when in contact with wound exudate to promote a moist wound environment.

NIHB does not cover any specific brand of dressing and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

13.4.3 Bandages

Bandages are used to cover, protect, and support wounds, injuries, or surgical sites, as well as to assist in the healing process by applying pressure, controlling swelling, or preventing infection. They come in various forms, such as gauze, elastic, impregnated, and tubular net dressings, designed to meet specific medical needs.

NIHB does not cover any specific brand of dressing and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

13.4.4 Compression bandages

Compression bandages are items used to assist and improve circulation through the application of gradient or consistent pressure therapy. These bandages are available in various pressure levels (mmHg) and can be single-use or can be washable and reusable.

NIHB does not cover any specific brand of dressing and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

13.4.5 Charcoal dressings

Dressings in this category contain activated charcoal that manages odours.

NIHB does not cover any specific brand of dressing and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

13.4.6 Composite dressings

Dressings in this category are considered multi-technology as they combine different features and functions into a single dressing.

• dressings with multiple features should be classified in this category only when they cannot be classified within another pre-established category, for example, silver

NIHB does not cover any specific brand of dressing and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

13.4.7 Eye

Items in this category are intended to protect the eye after an injury or surgery.

13.4.8 Foam dressings

Dressings in this category are typically made from polyurethane or silicone to form an absorbent foam that promotes moist wound healing.

• foam dressings that are impregnated with a solution, for example, PHMB, should be classified under this category and not under the non-adherent category
• foam dressings impregnated with silver, honey, or iodine, must be coded under their respective categories and not under foam
• foam dressings used for single-use negative pressure wound therapy (sNPWT) must be coded under the sNPWT category

NIHB does not cover any specific brand of dressing and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

13.4.9 Gauze

Gauze is composed of a loose open weave cotton. It is available in sterile and non-sterile packaging. Single-ply and multi-ply gauze should be requested under the most appropriate item code size.

13.4.10 Gel/hydrogel dressings

Dressings in this category are available as gels and impregnated dressings. Their main composition is a hydrophilic polymer that provides moisture to the wound bed and promotes rehydration. To be eligible for coverage, gel/hydrogel dressings must be in direct contact with the wound bed, meaning it must be a primary dressing.

NIHB does not cover any specific brand of dressing and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

13.4.11 Honey dressings

Dressings in this category are available as gels, pastes, or impregnated dressings. The main composition of these antibacterial dressings is medical grade honey. To be eligible for coverage, honey dressings must be in direct contact with the wound bed. for example, primary dressing.

NIHB does not cover any specific brand of dressing and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

13.4.12 Hydrocolloid dressings

Dressings in this category typically have 2 layers. The inner layer that is in contact with the wound produces a gel-like substance when in contact with wound exudate. The outer layer can be made of polyurethane film, foam, or both. While they typically allow moisture to evaporate through their membrane, many are waterproof and provide protection against outside contaminants.

• hydrocolloid dressings with alginate should be coded under this category

NIHB does not cover any specific brand of dressing and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

13.4.13 Iodine dressings

Dressings in this category are available as gels, ointments, pastes, impregnated sheets, and powders. The main composition of these antibacterial dressings is iodine. To be eligible for coverage, iodine dressings must be in direct contact with the wound bed, for example, primary dressing.

NIHB does not cover any specific brand of dressing and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

13.4.14 Non-adherent dressings

Dressings in this category are composed of different textiles such as woven or nonwoven silicone, gauze, or nylon. These dressings are designed to come in contact with the wound bed without adhering, for example, sticking, to the wound itself. Non-adherent dressings can be impregnated or non-impregnated.

Non-adherent impregnated dressings are saturated with a solution such as petrolatum, paraffin, chlorhexidine, sodium chloride, polyhexamethylene biguanide (PHMB), bismuth thiophanate, or zinc.

• foam dressings impregnated with a solution must be coded under the foam dressing category
• dressings impregnated with silver, honey, gels (hydrophilic polymers), or iodine must be coded under their respective category

NIHB does not cover any specific brand of dressing and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

13.4.15 Silver dressings

Dressings in this category are indicated for wounds with localized, spreading, or systemic infection. The main composition of these antibacterial dressings is silver. Silver dressings are available in various formats such as calcium alginate, foam, gauze, gel, gelling fibres, powder, etc. To be eligible for coverage, silver dressings must be in direct contact with the wound bed, for example, primary dressing, and remain in place for a minimum of 24 hours to be effective.

NIHB does not cover any specific brand of dressing and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

13.4.16 Single-use negative pressure wound therapy

NIHB does not cover any specific brand of dressing and the list below is not exhaustive. The items listed are examples of dressings that may be considered for coverage in this category.

Brand examples

• Hypafix Transparent (BSN Medical)
• Leukomed Control (BSN Medical)
• Mepitel Film (Mölnlycke)
• Mepore Film (Mölnlycke)
• Opsite Flexigrid (Smith&Nephew)
• Opsite Flexifix Transparent Film Roll (Smith&Nephew)
• Opsite Spray (Smith&Nephew)
• Tegaderm Absorbent Clear Acrylic Dressing (3M Health Care Business)
• Tegaderm Transparent Film Dressing (3M Health Care Business)
• Tegaderm Transparent Film Roll (3M Health Care Business)

Sterile dressing tray:

Sterile dressing trays are covered for dressings changed with a sterile technique. Sterile dressing trays are not covered for dressings that can be changed with a no-touch or clean technique.

The following information is required with every sterile dressing tray request:

• prior approval form including items listed in section 13.1.3 Prior approval requirements
• item make, model, manufacturer product code, quantity and cost
• prescription or recommendation. The Wound Care Assessment Form, when completed by an NIHB recognized prescriber or recommender for the requested item, is accepted as the recommendation or prescription for this item and a separate prescription or recommendation is not required
• frequency of dressing change
• client diagnosis, wound type :
  • examples of conditions and wound characteristics when sterile dressing trays are considered for coverage:
    • central line insertion site
    • chemotherapy or radiation recipient, up to 1 year since the last treatment date. Date must be provided
    • conservative sharp debridement when performed. The frequency must be provided
    • hemodialysis fistula until healed or matured
    • nonsurgical sinus or wound that connects to a body cavity, organ, tendon or bone
    • recipient of an organ or stem cell transplant taking antirejection or immunosuppression medication
    • stage IV pressure injury
    • surgical wound for up to 1 month after the date of surgery. Date must be provided
    • third degree burns
    • ulcer secondary to arterial occlusion
    • wound packing appropriate for wounds greater than 0.5 cm in depth
  • requests for wounds not listed above will be reviewed on a case-by-case basis. Supporting information should be submitted for consideration
  • a client with an infection may be eligible for coverage on a case-by-case basis. Supporting information should be submitted for review including the specific diagnosis, for example, cellulitis. Note that simply stating infection is insufficient information to support coverage
  • NIHB does not cover sterile dressing changes for clients at risk of infection
• any additional relevant information, for example, associated condition or medical justification to support the request

Wound care-related information can be submitted as part of the Wound Care Assessment Form, found on the Express Scripts Canada provider and client website.

13.6.1 Delivery