Pressure ModificationProduct Manual

Effective Date : February 5, 2020

Assistive Devices ProgramMinistry of Health

Ministry of Health Assistive Devices Program

Pressure Modification Effective Date: February 5, 2020

Lymphedema Management Devices Device Type Device Device Code Max

Allowed Qty

Approved Price

LM Mask LM Face Mask Face Masks VCCNDFA10 12 $182.33 LM Chin Strap / Neck Support

Facial Accessories VCCNDFA20 12 $39.40

LM Mask Accessories Chin Straps VCCNDFA30 12 $102.60 LM Trunk LM Vest - sleeveless Vest Sleeveless VCCNDVE10 12 $168.68 LM Vest - sleeves Vest With Sleeves VCCNDVE12 12 $374.35 LM Body Brief -sleeveless

Body Brief, Sleeveless VCCNDVE20 20 $280.43

LM Body Brief - sleeves Body Brief, With Sleeves VCCNDVE22 20 $371.08

Page: 2 of 12

Ministry of Health Assistive Devices Program

Pressure Modification Effective Date: February 5, 2020

Lymphedema Management Devices Device Type Device Device Code Max

Allowed Qty

Approved Price

LM Lower Extremity LM Foot Gloves Custom Non -Elastic, Foot Glove To Ankle LM0001002 8 $167.00

Custom Non-Elastic, Foot Glove To Knee LM0001003 8 $467.00 Custom/Premium: Non -Elastic, Foot Glove To Ankle

LM0001096 8 $90.00

Custom/Premium: Non -Elastic, Foot Glove To Knee

LM0001097 8 $455.00

Foot Glove To Ankle VCCNDFG10 12 $200.90 Foot Glove To Knee VCCNDFG12 12 $202.51 Foot To Ankle, Sock LM0000947 12 $119.00 Non-Elastic Foot Glove To Ankle LM0000998 8 $56.00 Non-Elastic Foot Glove To Knee LM0000999 8 $156.00 Prefabricated /Essential: Non- Elastic, Foot Glove To Ankle

LM0001093 8 $68.00

Prefabricated/Essential: Non-Elastic, Foot Glove To Knee

LM0001094 8 $167.00

Web Spacers For Foot Glove VCCNDFG14 12 $143.14 LM Foot Cap Custom Seamed Honeycomb Knit, Foot Cap VCCNDFG20 12 $167.17 LM Stockings - foot to knee

Custom Seamed Honeycomb Knit Stockings, Foot To Knee

VCCNDLE12 12 $167.17

Custom Seamed Stockings, Foot To Knee VCCNDLE11 12 $73.78 Custom Seamless Stockings, Foot To Knee VCCNDLE13 12 $69.12 Prefabricated Stockings, Foot To Knee VCCNDLE10 12 $67.62

LM Stockings - foot to thigh

Custom Non-Elastic, Foot To Mid Thigh LM0001004 8 $667.00 Custom Non-Elastic, Foot To Thigh LM0001005 8 $1,100.00 Custom Seamed Honeycomb Knit Stockings, Foot To Thigh

VCCNDLE19 12 $246.47

Custom Seamed Stockings, Foot To Mid Thigh VCCNDLE15 12 $117.16 Custom Seamed Stockings, Foot To Thigh VCCNDLE18 12 $91.04 Custom Seamless Stockings, Foot To Mid Thigh VCCNDLE16 12 $106.66 Custom Seamless Stockings, Foot To Thigh VCCNDLE20 12 $99.46

Page: 3 of 12

Ministry of Health Assistive Devices Program

Pressure Modification Effective Date: February 5, 2020

Lymphedema Management Devices Device Type Device Device Code Max

Allowed Qty

Approved Price

LM Lower Extremity LM Stockings - foot to thigh

Custom/Premium: Stockings , Non-Elastic, Foot To Thigh

LM0001098 8 $873.00

Non-Elastic, Foot To Mid-Thigh LM0001000 8 $227.00 Non-Elastic, Foot To Thigh LM0001001 8 $374.00 Prefabricated Stockings, Foot To Mid Thigh VCCNDLE14 12 $94.57 Prefabricated Stockings, Foot To Thigh VCCNDLE17 12 $92.32 Prefabricated/Essential: Stockings, Non -Elastic, Foot To Thigh

LM0001095 8 $387.00

LM Stockings - foot to thigh with waist attachment

Custom Seamed Stockings, Foot To Thigh With Waist Attachment

VCCNDLE22 12 $132.20

Custom Seamless Stockings, Foot To Thigh With Waist Attachment

VCCNDLE23 12 $133.76

Prefabricated Stockings, Foot To Thigh With Waist Attachment

VCCNDLE21 12 $71.24

LM Stockings - waist high (one leg)

Custom Seamed Honeycomb Knit Stockings, Waist High, One Full Leg, Panty, Closed Pubis

VCCNDLE26 12 $546.52

Custom Seamed Honeycomb Knit Stockings, Waist High, One Full Leg, Panty, Open Pubis

VCCNDLE30 12 $546.52

Custom Seamed Stocking, Waist High, One Full Leg, Panty, Closed Pubis

VCCNDLE25 12 $204.86

Custom Seamed Stockings, Waist High, One Stump, Panty

VCCNDLE67 12 $280.34

Custom Seamed Stockings, Waist High, One Full Leg, Brief

VCCNDLE33 12 $204.86

Custom Seamed Stockings, Waist High, One Full Leg, Panty, Open Pubis

VCCNDLE29 12 $218.19

Custom Seamed Stockings, Waist High, One Full Leg, Open Pubis

VCCNDLE38 12 $214.93

Custom Seamed Stockings, Waist High, One Full Leg, One Below Knee, Closed Pubis

VCCNDLE40 12 $280.41

Page: 4 of 12

Ministry of Health Assistive Devices Program

Pressure Modification Effective Date: February 5, 2020

Lymphedema Management Devices Device Type Device Device Code Max

Allowed Qty

Approved Price

LM Lower Extremity LM Stockings - waist high (one leg)

Custom Seamed Stockings, Waist High, One Full Leg, One Below Knee, Open Pubis

VCCNDLE42 12 $293.74

Custom Seamed Stockings, Waist High, One Leg, One Stump, Closed Pubis

VCCNDLE55 12 $294.57

Custom Seamed Stockings, Waist High, One Leg, One Stump, Open Pubis

VCCNDLE58 12 $307.90

Custom Seamed Stockings, Waist High, One Stump

VCCNDLE61 12 $185.09

Custom Seamless Stockings, Waist High, One Full Leg, Panty, Closed Pubis

VCCNDLE27 12 $191.81

Custom Seamless Stockings, Waist High, One Full Leg, Panty, Open Pubis

VCCNDLE31 12 $205.14

Custom Seamless Stockings, Waist High, One Full Leg, Open Pubis

VCCNDLE39 12 $205.14

Custom Seamless Stockings, Waist High, One Full Leg, Brief

VCCNDLE35 12 $191.81

Custom Seamless Stockings, Waist High, One Full Leg, One Below Knee, Closed Pubis

VCCNDLE41 12 $319.99

Custom Seamless Stockings, Waist High, One Full Leg, One Below Knee, Open Pubis

VCCNDLE43 12 $346.66

Custom Seamless Stockings, Waist High, One Leg, One Stump, Closed Pubis

VCCNDLE56 12 $319.99

Custom Seamless Stockings, Waist High, One Leg, One Stump, Open Pubis

VCCNDLE59 12 $346.66

Custom Seamless Stockings, Waist High, One Stump

VCCNDLE62 12 $166.66

Page: 5 of 12

Ministry of Health Assistive Devices Program

Pressure Modification Effective Date: February 5, 2020

Lymphedema Management Devices Device Type Device Device Code Max

Allowed Qty

Approved Price

LM Lower Extremity LM Stockings - waist high (one leg)

Custom Seamless Stockings, Waist High, One Stump, Panty

VCCNDLE68 12 $319.99

Prefabricated Stockings, Waist High, One Full Leg, Brief

VCCNDLE32 12 $185.66

Prefabricated Stockings, Waist High, One Full Leg, Open Pubis

VCCNDLE36 12 $131.33

Prefabricated Stockings, Waist High, One Full Leg, Panty, Closed Pubis

VCCNDLE24 12 $153.06

Prefabricated Stockings, Waist High, One Full Leg, Panty, Open Pubis

VCCNDLE28 12 $177.86

Prefabricated Stockings, Waist High, One Stump VCCNDLE60 12 $72.13 LM Stockings - waist high (two legs)

Custom Seamed Honeycomb Knit Stockings, Waist High, Two Full Legs, Closed Pubis

VCCNDLE46 12 $792.99

Custom Seamed Stockings, Waist High, Two Full Legs, Closed Pubis

VCCNDLE45 12 $210.23

Custom Seamed Stockings, Waist High, Two Full Legs, Open Pubis

VCCNDLE49 12 $219.13

Custom Seamed Stockings, Waist High, Two Stumps, Closed Pubis

VCCNDLE64 12 $294.57

Custom Seamless Stockings, Waist High, Two Full Legs, Closed Pubis

VCCNDLE47 12 $200.33

Custom Seamless Stockings, Waist High, Two Full Legs, Open Pubis

VCCNDLE50 12 $209.21

Custom Seamless Stockings, Waist High, Two Stumps, Closed Pubis

VCCNDLE65 12 $319.99

Prefabricated Stockings, Waist High, Two Full Legs,

VCCNDLE48 12 $177.86

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Ministry of Health Assistive Devices Program

Pressure Modification Effective Date: February 5, 2020

Lymphedema Management Devices Device Type Device Device Code Max

Allowed Qty

Approved Price

LM Lower Extremity LM Stockings - waist high (two legs)

Open Pubis Prefabricated Stockings, Waist High, Two Full Legs, Closed Pubis

VCCNDLE44 12 $128.28

LM Stockings - chest high

Custom Seamed Stockings, Chest High, Pregnancy, Two Legs

VCCNDLE52 12 $203.79

Custom Seamless Stockings, Chest High, Pregnancy, Two Legs

VCCNDLE53 12 $211.58

Prefabricated Stockings, Chest High, Pregnancy, Two Legs

VCCNDLE51 12 $136.66

LM Stockings - chaps style (one leg)

Custom Seamed Stockings, Chaps Style, One Leg, Panty, Knee Ankle, No Foot

LM0000948 12 $239.00

Custom Seamed Honeycomb Knit Stockings, Chaps Style, One Leg

VCCNDLE78 12 $342.91

Custom Seamed Stockings, Chaps Style, One Leg VCCNDLE77 12 $146.13 Custom Seamed Stockings, Chaps Style, One Stump

VCCNDLE81 12 $176.62

Custom Seamless Stockings, Chaps Style, One Leg

VCCNDLE79 12 $133.53

Custom Seamless Stockings, Chaps Style, One Stump

VCCNDLE82 12 $166.66

Prefabricated Stockings, Chaps Style, One Leg VCCNDLE76 12 $68.86 Prefabricated Stockings, Chaps Style, One Stump VCCNDLE80 12 $72.13

LM Stockings - chaps style (two legs)

Custom Seamed Honeycomb Knit Stockings, Chaps Style, Two Leg

VCCNDLE71 12 $685.84

Custom Seamed Stockings, Chaps Style, Two Legs VCCNDLE70 12 $250.15 Custom Seamed Stockings, Chaps Style, Two Legs, Panty, Knee Ankle, No Feet

LM0000949 12 $248.00

Custom Seamed Stockings, Chaps Style, Two Stumps

VCCNDLE74 12 $264.03

Custom Seamless Stockings, Chaps Style, Two Legs

VCCNDLE72 12 $283.27

Page: 7 of 12

Ministry of Health Assistive Devices Program

Pressure Modification Effective Date: February 5, 2020

Lymphedema Management Devices Device Type Device Device Code Max

Allowed Approved

Price Qty

LM Lower Extremity LM Stockings - chaps style (two legs)

Custom Seamless Stockings, Chaps Style, Two Stumps

VCCNDLE75 12 $246.66

Prefabricated Stockings, Chaps Style, Two Legs VCCNDLE69 12 $159.00 Prefabricated Stockings, Chaps Style, Two Stumps VCCNDLE73 12 $155.13

Page: 8 of 12

Ministry of Health Assistive Devices Program

Pressure Modification Effective Date: February 5, 2020

Lymphedema Management Devices Device Type Device Device Code Max

Allowed Qty

Approved Price

LM Upper Extremity LM Glove Custom Honeycomb Glove, Fingers To Wrist VCCNDGL13 12 $568.00

Custom Non-Elastic Glove LM0000569 8 $220.00 Custom Seamed Glove, Fingers To Wrist VCCNDGL11 12 $201.82 Custom Seamless Glove, Fingers To Wrist VCCNDGL12 12 $93.33 Prefabricated Glove, Fingers To Wrist VCCNDGL10 12 $136.44 Prefabricated Honeycomb Glove, Fingers To Wrist VCCNDGL14 12 $371.00

LM Gauntlet Custom Honeycomb Gauntlet, Metacarpals To Wrist

VCCNDGA22 12 $241.00

Custom Seamed Gauntlet, Metacarpals To Wrist VCCNDGA21 12 $70.82 Prefabricated Gauntlet, Metacarpals To Wrist VCCNDGA20 12 $38.17

LM Arm Sleeve - 1/2 Custom Seamed Arm Sleeve, 1/2 Without Glove VCCNDAR01 12 $91.10 Prefabricated Arm Sleeve, 1/2 Without Glove VCCNDAR00 12 $53.33

LM Arm Sleeve - 1/2 with glove

Custom Seamed Arm Sleeve, 1/2 With Glove VCCNDAR04 12 $202.22 Prefabricated Arm Sleeve, 1/2 With Glove VCCNDAR03 12 $60.00

LM Arm Sleeve - full Custom Honeycomb Arm Sleeve, Wrist To Axilla VCCNDAR17 12 $306.00 Custom Non-Elastic Arm Sleeve, Wrist to Axilla LM0000568 8 $253.00 Custom Seamed Arm Sleeve, Wrist To Axilla VCCNDAR07 12 $112.65 Custom Seamless Arm Sleeve, Wrist To Axilla VCCNDAR08 12 $151.73 Prefabricated Arm Sleeve, Wrist To Axilla VCCNDAR06 12 $52.87

LM Arm Sleeve - full with glove

Custom Seamed Arm Sleeve, Wrist To Axilla With Glove

VCCNDAR10 12 $166.97

Prefabricated Arm Sleeve, Wrist To Axilla With Glove

VCCNDAR09 12 $57.33

LM Arm Sleeve - with shoulder flap

Custom Seamed Arm Sleeve, Wrist To Axilla With Shoulder Flap

VCCNDAR13 12 $155.24

Custom Seamless Arm Sleeve, Wrist To Axilla With Shoulder Flap

VCCNDAR14 12 $182.13

Prefabricated Arm Sleeve, Wrist To Axilla With Shoulder Flap

VCCNDAR12 12 $58.65

LM Arm Sleeve - with Custom Seamed Arm Sleeve, Wrist To Axilla With VCCNDAR16 12 $239.01

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Ministry of Health Assistive Devices Program

Pressure Modification Effective Date: February 5, 2020

Lymphedema Management Devices Device Type Device Device Code Max

Allowed Qty

Approved Price

LM Upper Extremity shoulder flap & glove Shoulder Flap

And Glove Prefabricated Arm Sleeve, Wrist To Axilla With Shoulder Flap And Glove

VCCNDAR15 12 $60.00

LM Compression Sleeves LM Compression Sleeves Upper Extremity

Reidsleeve Classic Upper Extremity VCKNDRD01 2 $948.00

LM Compression Sleeves Glove

Reidsleeve Classic Glove VCKNDRD02 2 $506.00

LM Compression Sleeves Lower Extremity

Reidsleeve Classic Lower Extremity VCKNDRD03 2 $1,454.00

LM Compression Sleeves Lower 1/2 Extremity

Reidsleeve Classic Lower 1/2 Extremity VCKNDRD04 2 $1,121.00

LM Compression Sleeves Gauge

Reidsleeve Precise Gauge VCKNDRD05 1 $159.00

LM Sequential Extremity Pumps & Accessories LM Sequential Extremity Pump

Extremity Pump VCVNDPP01 1 $3,799.05

LM Medical Overlapping Pants

Medical Overlapping Pants VCVNDPA01 1 $1,650.26

LM Sequential Extremity Pump Accessories

Adapter VCVNDAD01 1 $233.00 Adult Boot One Cell VCVNDBO01 2 $259.14 Expanders VCVNDEX01 18 $120.02 Hose Bundle VCVNDHB01 2 $183.12 Shoulder Attachments VCVNDSA01 2 $69.54 Velcro Sleeves VCVNDVS01 4 $450.70 Zipper Sleeves VCVNDZS01 4 $482.89

Page: 10 of 12

Ministry of Health Assistive Devices Program

Pressure Modification Effective Date: February 5, 2020

Lymphedema Management Devices Device Type Device Device Code Max

Allowed Qty

Approved Price

LM Options - Garments LM Options - Garments Abdominal Panels VCCNDOP12 12 $81.34

Attachment Charge, Glove To Sleeve, Honeycomb VCCNDOP27 24 $76.00 Briefs VCCNDOP20 12 $239.99 Contracture Seams VCCNDOP21 48 $12.09 Custom Honeycomb Bra Loop VCCNDOP26 24 $144.00 Custom Honeycomb Shoulder Cap VCCNDOP25 24 $144.00 Elbow Reinforcements VCCNDOP16 24 $20.61 Fingers - Each VCCNDOP05 120 $26.67 Glove Or Gauntlet Extension, Honeycomb VCCNDOP28 24 $153.00 Heel/Ankle Reinforcements VCCNDOP13 24 $21.48 Honeycomb Stretch Elbow & Knee Lining LM0000944 36 $67.00 Knee Reinforcements VCCNDOP14 24 $23.13 Linings, Includes All VCCNDOP18 48 $26.67 Ostomy Openings VCCNDOP19 12 $17.45 Oversize Charge VCCNDOP24 24 $22.08 Shoulder Strap VCCNDOP01 12 $72.00 Silicone Bands VCCNDOP03 72 $17.35 Suspenders VCCNDOP11 12 $35.67 Thigh Reinforcements VCCNDOP15 24 $31.05 Toes, Self VCCNDOP22 120 $18.83 Toes, Soft VCCNDOP23 60 $17.80 Velcro VCCNDOP17 36 $14.31 Web Spacers VCCNDOP04 24 $111.17 Zipper VCCNDOP10 36 $39.28 Zipper, Honeycomb VCCNDOP29 96 $87.00

Page: 11 of 12

Ministry of Health Assistive Devices Program

Pressure Modification Effective Date: February 5, 2020

Lymphedema Management Devices -ManufacturersGarments

BSN Medical (Jobst, Farrowmed)

J. Vaillancourt Corporation Ltd.

Juzo

LympheDIVAS

Sigvaris Corporation (Biacare)

Solaris Inc. (Ready-Wrap)

Valco-Mediven Inc. (Elastic, Juxta-Fit)

Venosan Canada Inc.

Recovery Garment Centre Inc.

Compression Sleeves (night-time garment)

Peninsula Medical Inc. (Reidsleeve Classic)

Sequential Extremity Pumps

Lymphapress

Biocompression Systems Inc.

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