Alberta Health Superseded · Custom made from cast O215False $1,825.04 Each TLSO 1 Spinal Orthosis Per 2 Years Custom made from measurement O506False $1,348.27 Each TLSO 1 Spinal

Alberta Health

AADL Approved Product List - Orthotic Benefits

Pricing effective October 16, 2017

© 2013 Government of Alberta April 1, 2014

Supers

eded

Functional Outcomes

Generic Pricing Procedure

General Information

100 Restrict range of motion of a joint to reduce/prevent the need for surgical or medical treatment101 Restrict range of motion of a joint to reduce/control tone or spasticity102 Control spinal deformity (e.g., scoliosis)103 Protection of a body part (e.g., helmet)104 Improve function by providing stability of the joint105 Improve function by positioning body part for activities of daily living106 Improve function by assisting muscle weakness107 Improve function by enabling lying, sitting, and standing (likely the more disabled client)108 Improve function by enabling walking and/or increased walking efficiency/endurance109 Facilitate healing of a body part110 Reduce pain (e.g., arthritis-related)111 Support soft tissue (e.g., hernia)112 Repairs

Use the AADL Generic Calculator to determine the AADL price for a generic catalogue number. Generic catalogue numbers can be indentified as they have their price is indicated as a "Max". Most generic catalogue numbers start with an "N". All generic catalogue numbers are considered to be "Upgrades". Refer to the General Policies and Procedure Manual for more information about upgrade costs.

Procedure

Locate the catalogue number and enter the manufacturer invoice cost for the component into the calculator. Do not include shipping costs, exchange or any other cost. The cost used for generic catalogue number must be the manufacturer's invoice cost only. The calculator will automatically add mark-up, shipping and labour costs.

Copy and paste the calculation into the Benefit Note on E-Business. Be sure to also indication the manufacturer and model number in the Benefit Note

Costs over the indicated maxmimum are indicated in the calculator and are considered an upgrade.


Page 2 of 26

Alberta Health - Pharmaceutical and Supplementary BenefitsAlberta Aids to Daily Living Manual O - Orthotics Approved Product List

© 2017 Government of AlbertaRevised October 16, 2017

APL O-1

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Orthotic Types

AFO ANKLE FOOT ORTHOSISCF CLUBFOOT ORTHOSISCO CERVICAL ORTHOSIS

CTLSO CERVICAL THORACIC LUMBAR SACRAL ORTHOSISEO ELBOW ORTHOSIS

HELMET HELMETHERNIA CUSTOM MADE HERNIA

HIPO HIP ORTHOSISHKAFO HIP KNEE ANKLE FOOT ORTHOSISKAFO KNEE ANKLE FOOT ORTHOSIS

KO KNEE BRACELSO LUMBAR-SACRAL ORTHOSISNRS NON-RIGID SPINAL ORTHOSISPR PARTIAL FOOT PROSTHESIS/ORTHOSIS

RGO RECIPROCATING GAIT ORTHOSISSO SHOULDER ORTHOSIS

THKAFO THORACIC KNEE ANKLE FOOT ORTHOSISTLSO THORACIC LUMBAR SACRAL ORTHOSISWHO WRIST HAND ORTHOSIS


Page 3 of 26



APL O-2

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andrea.waywanko

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###Spinal Orthoses

Cat. No. AADL PriceOrth. Type

###Cervical Orthoses

Prescription Required

C.O.

FalseO166Custom Made - Molded to patient model, cervical and thoracic control (Minerva type)

$2,653.84 Each

CO

1 Spinal Orthosis Per 2 Years

FalseO168Custom Made - molded to patient model, cervical and thoracic control (Minerva type) plus interface

$2,671.59 Each

CO


FalseO088Molded to patient model $897.57 EachCO


FalseO084Prefabricated C.O. which requires custom fitting (e.g. Philadelphia or thermoplastic designs or equivalent)

$206.42 Each

CO


FalseO090With occipital/mandibular supports with thoracic extensions for increased cervical control, custom-fitted (e.g. S.O.M.I., Fi-way, La-cal, Guilford or equivalent)

$510.79 Each

CO, CTLSO


Hensinger Head Support

FalseO300 $441.17 EachCO

1 Head Support Per 2 Years

###Thoracic Orthoses


Pectus Brace

FalseO342 $1,131.59 EachTLSO

1 Thoracic Brace Per 2 Years

###Rigid Spinal Orthoses


Rigid Spinal Orthosis

FalseO135Custom Made $1,404.14 EachLSO


FalseN117Generic Custom Fitted $721.54 Max. EachLSO, TLSO


###Additions to Rigid Spinal Orthoses

Bariatric Option

False

Client is 100 lb. over normal weight or over 275 lb. Must indicated criteria in E-Business Benefit Note.

O497 $233.00 EachCTLSO, LSO, TLSO

1 Rigid Spinal Addition Per 2 Years

Corset front

FalseO150As opposed to apron front $178.98 EachLSO



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APL O-3

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###Spinal Orthoses


###Additions to Rigid Spinal Orthoses

Full corset

FalseO152As opposed to apron front $134.73 EachLSO


Sub-Clavicular Extensions

FalseO148For rotary control $167.11 EachLSO, TLSO


###Total Contact T.L.S.O. (Body Jacket)


May be provided to a client who has had a spinal fracture or surgical intervention, when the orthotic is required for discharge from a general hospital. Vendor must clearly document clinical assessment and discharge plan.

Must indicate clinical rationale in E-Business Benefit Note.

Boston Jacket

FalseO215Custom made from cast $1,825.04 EachTLSO


FalseO506Custom made from measurement $1,348.27 EachTLSO


FalseO505Soft - Stock $1,287.23 EachTLSO


Boston Orthosis

FalseO213Custom from cast $1,851.39 EachTLSO


FalseO211Custom from measurement $1,755.17 EachTLSO


FalseO218Stock custom fitted $1,766.37 EachTLSO


Boston Overlap Orthosis or Equivalent

FalseO219Molded to patient $1,379.33 EachTLSO


T.L.S.O.

FalseO123Molded antero-posterior design $2,468.27 EachTLSO


FalseO125Molded antero-posterior design with interface $2,613.62 EachCTLSO, TLSO


FalseO122Molded to patient model $2,334.70 EachTLSO


FalseO124Molded to patient model with interface $2,480.23 EachTLSO


FalseO127Posterior, Anterior shell only with corset or equivalent front

$1,878.40 Each

TLSO



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###Spinal Orthoses


###Total Contact T.L.S.O. (Body Jacket)


May be provided to a client who has had a spinal fracture or surgical intervention, when the orthotic is required for discharge from a general hospital. Vendor must clearly document clinical assessment and discharge plan.

Must indicate clinical rationale in E-Business Benefit Note.

T.L.S.O.

FalseO220Scoliosis procedure - Molded to patient model with interface

$2,571.68 Each

TLSO


###C.T.L.S.O. - Milwaukee


Complete Milwaukee Orthosis

False

No additions

O188Initial $3,284.44 EachCTLSO


###Protective Helmet


CriteriaMust be required for daily use for protection in cases of self-abusive behaviour, seizure disorder, and protect/facilitate healing of chronic wounds or cranial defects.

Must indicate criteria in E-Business Benefit Note.

Custom Fitted Helmet

False

Orthotist must in E-Business Benefit Note indicate why commercial (e.g. bicycle, mountain climbing, etc.) helmets are inadequate.

O051A modular helmet system requiring measurement, modification of modular parts and assembly, based on DANMAR helmet.

$1,103.07 Each

HELMET

1 Helmet Per 2 Years

Helmet Molded to Patient Model.

False

Orthotist must in E-Business Benefit Note indicate why commercial (e.g. bicycle, mountain climbing, etc.) helmets are inadequate.

O053Helmet made with high temperature thermoplastic with liner.

$1,494.39 Each

HELMET

1 Helmet Per 2 Years


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###Lower Extremity Orthoses


###Hip Abduction Control


Dennis Brown Plate

FalseO306 $224.17 EachAFO, HIPO

1 L/E Orthosis Per 2 Years

Dynamic Brace

FalseO241Pelvic control, adjustable hip motion control, thigh cuffs (Rancho Hip Action Design)

$2,134.39 Each

HIPO


Static Adjustable

FalseO235Custom Fitted $1,059.13 EachHIPO


Static Foam or Thermoplastic Design

FalseO237Custom Fitted (Von Rosen or equivalent) $366.24 EachHIPO


FalseO238Custom Made (Von Rosen or equivalent) $748.10 EachHIPO


Static Pelvic Band or Spreader Bar

FalseO233Custom Fitted - with thigh cuffs $545.85 EachHIPO


###Torsion Control


Pelvic Band/Belt

FalseO294With bilateral rotation straps $519.99 EachHIPO

1 Pelvic Band/Belt Per 2 Years

FalseO298With torsion cables and ball bearing hip joints, bilateral cable usage

$1,261.84 Each

HIPO


FalseO297With torsion cables and ball bearing hip joints, unilateral cable usage hip joints, unilateral cable usage

$868.79 Each

HIPO


###Abduction and Rotation Control


Atlanta or Scottish-Rite Trilateral Orthosis

FalseO305 $2,107.68 EachHIPO


SWASH

FalseO242 $2,039.66 EachHIPO, RGO



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###Knee Orthosis to Prevent Knee Flexion

Prescription RequiredCriteria

Required for 6 months and longer, for full-time activities of daily living and/or full-time activities at work. Full-time isdefined as a minimum of 6 hours per day, every day. Not eligible for post-operative care or short-term need.

Prescriber must be one of the following specialist physicians: orthopedics, physiatry, rheumatology, geriatrics.

Must indicate clinical condition in E-Business Benefit Notes (example: failed knee replacement or knee fusion).

Total Contact Cylinder Orthosis

FalseO257High temp. thermoplastics, molded to patient model $1,024.40 EachKO


FalseO256Low temp. thermoplastics, molded directly to patient $559.70 EachKO


###Knee Hyperextension Orthoses

Prescription RequiredCriteria

Required for 6 months and longer, for full-time activities of daily living and/or full-time activities at work. Full-time isdefined as a minimum of 6 hours per day, every day.

Must indicate clinicial condition in E-Business Benefit Note.

Generic Hyperextension Control Knee Orthosis

FalseN317Custom Fitted $800.40 Max. EachKO


###Dynamic Knee Extension Assist Orthoses


Criteria

Must be used for maintaining or increasing range of motion at the knee for clients with chronic flexion contractures.

Clients are typically diagnosed with neuromuscular conditions (CP, Stroke) and are must not be candidates forserial casting due to practical limitations of this option (swelling, access to service).

The benefit cannot be provided to clients that require post-op ROM braces for short-term.

Must indicate criteria in E-Business Benefit Note.

Dynamic Knee Extension Assist Orthoses

FalseO550 $761.40 EachKO



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###Unloading Knee Orthoses

Criteria

Must be required for 6 months and longer, for full-time activities of daily living and/or full-time activities at work.Full-time activity is defined as a minimum of 6 hours per day, every day.

Must have severe valgus or varus deformity and joint space narrowing.

Prescriber

Must be one of the following specialist physicians: orthopedics, physiatry, rheumatology, geriatrics, neurology,pediatrics.

Prescriptions from other physicians will only be accepted if accompanied by an x-ray report indicating moderate orsevere osteoarthritis.

AADL will provide funding for "minor or mild" OA or degenerative changes, if the Orthotist documents that unloading or realignment of the joint resulted in a functional pain relief (improved ambulation). Realignment can be demonstrated by an off-the-shelf bracing trial or taping techniques. The outcome must be documentd in the E-Business Benefit Note.

Clients must be offered a choice of unloading knee braces to address their assessed medical need at or below AADL's maximum contribution. "Upgrade" indicates a product whose cost exceeds the AADL maximum contribution, any additional cost is a client's choice and responsibility.

Unloading Knee Orthosis

False

Procedure to be added, not other additions.

N730Generic CFAB (Custom) $1,141.45 Max. Each

KO


False


N712Generic Custom Fit (OTS) $782.12 Max. EachKO


False

Procedure and joints to be added

O537In-House (Custom) - Laminate $1,214.77 EachKO


False


O259In-House (Custom) - Plastic $851.40 EachKO

1 L/E Orthosis Per 4 Year

Unloading Knee Orthosis Procedure

FalseO551CFAB (Custom) $563.69 EachKO

1 KO Procedure Per 4 Years

FalseO501In-House Custom Procedure $652.19 EachKO


FalseO565Presized OA $354.00 EachKO



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###Stabilizing Knee Orthoses

Criteria

Must be required for 6 months and longer, for full-time activities of daily living and/or full-time activities at work.Full-time activity is defined as a minimum of 6 hours per day, every day.

Must meet either the "Orthopedic Criteria" or "Neurological Criteria" listed below.

Criteria must be indicated in E-Business Benefit Note.

Orthopedic CriteriaMust meet one of the following four criteria:1. Gross knee instability resulting from partial/total knee replacement. Prescriber: Physician.2. A single ligament tear with a meniscus removed or two ligaments with 2nd or 3rd degree tears. A prescription oran MRI or an arthroscopic report documenting the orthopedic condition will be accepted.*3. Ligament instability and client has a vocation that is physically demanding and requires bracing. Examples:construction worker, healthcare worker, police, oilfield worker, farmer. The vocation must be indicated on the authorization.*4. Ligament instability and client is not a surgical candidate. Examples: skeletal immaturity, medical condition, age,failed surgical repair.*5. MRI demonstrates complete tear of two ligaments and surgery not scheduled for six months.**Prescriber for Criteria 2, 3, 4 and 5: One of the following specialist physicians: orthopedics, physiatry,rheumatology, geriatrics, neurosurgery, neurology, pediatrics or a physician with a diploma in Sports Medicine from the Canadian Academy of Sport and Exercise Medicine.

Neurological CriteriaA progressive or chronic neurological condition that results or will result in severe knee instability due to weakening of quadriceps or spasticity at the knee (diagnosis of condition must be indicated on prescription). Brace must be used for ambulation. Prescriber: Physician.

Clients must be offered a choice of stabilizing knee braces that are available to address their identified medical need at or below AADL’s maximum contribution.“Upgrade” indicates a product whose cost exceeds the AADL maximum contribution, any additional cost is a client’s choice and responsibility.

Stabilizing Knee Orthosis

False


N700Generic CFAB (Custom) $1,170.60 Max. Each

KO


False


N722Generic Custom Fit (OTS) $785.05 Max. EachKO


False


O545In-House Custom - Plastic $851.40 EachKO


False

Procedure and Joints to be added

O546In-House Custom - Laminate $1,214.77 EachKO


Stabilizing Knee Orthosis Procedure

FalseO570CFAB Custom $563.69 EachKO


FalseO571Custom Fit (OTS) $354.00 EachKO


FalseO507In-House Custom $652.19 EachKO



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###Ankle Foot Orthoses (AFO)


AFO

FalseO288Anterior Floor Reaction $1,343.48 EachAFO


False

Check socket should be used. Criteria - Severe deformity and greater than or equal to 200 lbs. and rotational stability required. Must indicate criteria in E-Business Benefit Note.

O265Composite plastic molded to patient model layered lamination/carbon fibre

$2,217.38 Each

AFO


FalseO280Conventional with double uprights, calf band and free ankle

$771.27 Each

AFO


FalseO278Conventional with single upright, calf band and free ankle

$638.52 Each

AFO


False

Criteria: Charcot Ankle Joint. Criteria must be inticated in E-Busniess Benefit Note.Clients cannot have custom made footwear and a CROW.

O602CROW (Bivalved AFO lined with Rocker Sole) $2,372.98 EachAFO


FalseO272Custom-made to paitent model - Single form $1,249.68 EachAFO


FalseO369Custom-made to patient model - Double form $1,654.66 EachAFO


False

Active community ambulator, plantar flexion weakness, quads good. Must indicate criteria in E-Business Benefit Note.

O578Energy Storing/Return Ankle Foot Orthosis $1,703.93 EachAFO


FalseN280Generic Pre-Fab $881.58 Max. EachAFO


False

Client not eligible for day and night AFO. Definitive brace policy confirmed with Physician. If KAFO required within 1 year, cost of AFO deducted.

E601Night Splints for Neuromuscular Peds $297.90 EachAFO


FalseO275PTB Prosthetic BK type socket molded to patient model with double uprights and free ankles

$1,962.98 Each

AFO


FalseO277PTB, plastic molded to patient model ant/post shell $1,962.98 EachAFO


False

Combined midfoot and hindfoot instability causing severe valgus or varus deformity at the ankle as a result of neuromuscular conditions such as CP, Spina Bifida, Down's Syndrome or orthopedic conditions such as post tibial dysfunction. Client's with soft tissue inflammatory conditions are not eligible. Must indicate criteria in E-Business Benefit Note.

O155Supra malleolar - High temperature thermoplastic molded to patient model.

$1,010.84 Each

AFO



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###Ankle Foot Orthoses (AFO)


Check for AFO

False

Skinny & boney prominent patients, Valgus / Varus greater than 10 – 15 degrees, severe sagital deformity, rotational deformity, high body weight, unstable midfoot, scarring or adhesions greater than 8 square cm.Criteria MUST be indicated in E-Business Benefit Note.

N309 $424.28 EachAFO

1 Check AFO Per 2 Years

###Knee Ankle Foot Orthoses (KAFO)

Prescription RequiredJoint to be added.

Check for KAFO

False

Skinny & boney prominent patients, Valgus / Varus greater than 10 – 15 degrees, severe sagital deformity, rotational deformity, high body weight, unstable midfoot, scarring or adhesions greater than 8 square cm.Criteria MUST be indicated in E-Business Benefit Note.

N310 $626.73 EachKAFO

1 Check KAFO Per 2 Years

KAFO

FalseO287Conventional - double upright $1,909.63 EachKAFO


FalseO283Conventional - single upright $1,510.16 EachKAFO


FalseO285Conventional - single upright without knee joint $1,510.16 EachKAFO


FalseO299Graphite - double upright $3,710.78 EachKAFO


FalseO293Hybrid - double upright $2,566.32 EachKAFO


FalseO292Hybrid - single upright $2,273.83 EachKAFO


FalseO291Plastic - double upright $2,566.32 EachKAFO


FalseO290Plastic - single upright $2,063.31 EachKAFO



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###Stance Phase KAFO


Criteria

weak quadriceps mechanism

adequate hip flexion and extension power

no spasticity

no knee flexion contracture > 10 degrees

no hip flexion contracture > 220 lbs.

good balance

good cognition


Any comparable quality system to below listed items may be substituted with AADL prior approval.

Stance Phase KAFO

FalseO232Free Walk Ottobock170K1=L-120-OBA-7

$3,888.96 Each

KAFO


###Additions to Lower Extremity Othoses

Total limit of 5 additions per orthoses. No duplicate additions permitted, except if indiviudal sides (medial and lateral) are authorized seperately, such as joints which are listed as "per side"

Ankle Joints

FalseN308Generic Ankle Joints $240.32 Max. Per Side

AFO, HKAFO, KAFO, THKAFO

5 L/E Additions Per 2 Years

Bail Locks Bar or Equivalent

False

To be added if the bail lock is activated by an extension assist, cable release, or other remote method, or in the case of bi-lateral joint uprights, the bail is contoured and attached to both joints. If only a single hinge/lock claim for 1/2 of price max.

O343 $330.07 Per PairKAFO, KO


Bariatric Option

False

Client is 100 lb. over normal weight or over 275 lb. Must indicate criteria in E-Business Benefit Note.

O498Lower Extremity Orthosis $349.50 EachAFO, HKAFO,

KAFO, THKAFO


Becker Cable Control for Trigger Lock

FalseO184MX003-HS/R $396.69 EachAFO, KAFO, KO


Calf Band

FalseO349Custom molded to patient model $399.36 EachAFO, KAFO


Calf Lacer

FalseO334Full, molded to patient model $525.28 EachKAFO



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APL O-12

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Total limit of 5 additions per orthoses. No duplicate additions permitted, except if indiviudal sides (medial and lateral) are authorized seperately, such as joints which are listed as "per side"

Calf Lacer

FalseO330Half, non-molded $239.99 EachKAFO


Custom Fabricated Flexible Interface

False

Criteria: For unstable, high tone, or severe foot deformity. Criteria must be indicated in E-Busniess Benefit Note.

O579 $289.05 EachAFO, KAFO


Dorsi Flexion Stop

FalseO351Custom $293.50 EachAFO, KAFO


Drop Lock or Equivalent

False

To be added if the addition of magnets or corking screws are incorporated into the fabrication procedure. If only a single hinge/lock claim for 1/2 of price maximum

O341 $184.08 Per PairHKAFO, KAFO,

THKAFO


Extension for Lineal Adjustment for Growth for Side

Bars

FalseO388 $200.04 EachKAFO, THKAFO,

RGO


Hip Joints

FalseO381Clevis type or thrust bearing, free $665.29 EachHKAFO, KAFO


Ischial Ring

FalseO366 $618.59 EachKAFO


Joint Covers

FalseO363 $135.90 Per PairKAFO


Knee Cage

FalseO359Pull Over $510.59 EachKAFO


FalseO357Standard $420.09 EachKAFO


Knee Joints

FalseO391Adjustible Extension Ring Lock - Becker 1006 $302.24 EachKAFO, KO


FalseO379Automatic Spring Lever - Becker 1003 $347.34 EachKAFO, KO


False

If only a single hinge/lock claim for 1/2 of price maximum

O345Disc or Dial Lock Joints for Adjustable Knee or Equivalent

$426.26 Per Pair

KAFO, KO



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Total limit of 5 additions per orthoses. No duplicate additions permitted, except if indiviudal sides (medial and lateral) are authorized separately, such as joints which are listed as "per side"

Knee Joints

FalseO375Free Motion/Ring Lock - Becker - 1002/1005/1008 $248.84 EachKAFO, KO


FalseO373Free Motion/Ring Lock - Ottobock 17B43=16 $210.24 EachKAFO


FalseN699Generic $448.20 Max. EachNone


FalseO352Offset Bail Locks 17B33 or Equivalent $533.88 EachKAFO


FalseO350Offset Drop Locks 17B20 or Equivalent $242.85 EachKAFO


FalseO371Polycentric - Ottobock 17B46 $439.90 EachKAFO


FalseO377Polycentric Knee Joint - Becker $358.14 EachKAFO, KO


FalseO399Ratchet Lock - Becker $347.79 EachKAFO, KO


FalseO401Step Loc - OTS Corp $389.42 EachKAFO, KO


FalseO380Swiss Lock - Ottobock 17B36/17B48 $361.00 EachKAFO, KO


Locking Knee Hinge(s) or Equivalent

FalseO477For custom-made stabilizing knee orthosis $285.56 EachKO


FalseO479For custom-made unloading knee orthosis $285.56 EachKO


Molded Foot Section Attached to Stirrup

FalseO353 $743.68 EachAFO, KAFO


Pad

FalseO386Gluteal $148.93 EachHKAFO, KAFO,

THKAFO


FalseO358Sub Patellar $51.16 EachKAFO


Pelvic Band, Belt and Hip Joint

FalseO384Bilateral $1,696.74 EachHKAFO, KAFO


FalseO382Unilateral $1,094.03 EachHKAFO, KAFO


Plantar Flexion Stop

FalseO354Custom $161.75 EachAFO, KAFO



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Total limit of 5 additions per orthoses. No duplicate additions permitted, except if indiviudal sides (medial and lateral) are authorized separately, such as joints which are listed as "per side"

Pre-Tibial or Femoral Shell

FalseO336Molded to patient model $434.85 EachAFO, HKAFO,

KAFO, THKAFO


Quadrilateral Brim

FalseO368Molded to patient model $867.99 EachKAFO


RGO (Reciprocating Gait Orthosis)

False

Contact AADL for prior approval of price.

O387Pelvic assembly and jacket only, does not include KAFO's.

Prior Approval

KAFO, RGO


Round Caliper Plate



Specialized Strap

False

High extensor tone requires additional strap. Must indicate criteria in E-Business Benefit Note.

O413Dorsal Ankle Strap (retention) $47.40 EachAFO


False

Quantity Limit: 1 per 2 years, except 2/2 years with O314, O316

O415Valgus or Varus "T" Straps $119.96 EachAFO, KAFO


Stirrup

FalseO367Spilt stirrup and flat caliper plate or solid sturrip $290.83 EachAFO, KAFO


Thigh Lacer

FalseO374Full, molded to patient model $620.28 EachKAFO


FalseO372Full, non-molded $422.36 EachKAFO


FalseO376Half, custom made $365.09 EachKAFO



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APL O-15

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###Stance Phase Knee Joint


Criteria

weak quadriceps mechanism

adequate hip flexion and extension power

no spasticity

no knee flexion contracture > 10 degrees

no hip flexion contracture > 220 lbs.

good balance

good cognition


Any comparable quality system to below listed items may be substituted with AADL prior approval.

Becker Load Response

FalseO240 $1,219.36 EachKAFO

1 Joint Per 2 Years

Horton Stance Phase


2 Joints Per 2 Years

Stance Phase Knee Joint - Fillauer Swing Phase Lock


1 Joint Per 2 Years

###Thoracic-Hip-Knee-Ankle Orthoses

Prescription RequiredAny comparable quality system to below listed items may be substituted with AADL prior approval.

Parapodium

FalseO224Small/large (Variety Village style) $2,600.25 EachTHKAFO


Recycle fee

False

25% of list of: O224, O226, O227, O222, O302, O242

O517THKAFO

1 Recycle Fee Per Limb Per 4 Years

Standing Frame

FalseO226Custom fitted (Variety Village style) $1,695.23 EachTHKAFO


FalseO227Custom Made $2,344.47 EachTHKAFO


Winnipeg Standing Frame

FalseO222 $2,273.70 EachTHKAFO



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APL O-16

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###Additions to Footwear

Transfer Of Caliper Plate From Shoe To Shoe

FalseO442 $355.90 EachAFO

2 Transfers Per 2 Years

Transfer of Dennis Brown Foot Plates To New Shoes

FalseO446 $181.22 EachAFO, HIPO


Transfer Of Solid Stirrup From Shoe To Shoe



###Partial Foot Prostheses


Partial Foot Prosthesis

False

No additions

O207AFO Style Partial Foot Prosthesis $2,331.50 EachPF


False

No additions

O087Custom Foot Orthosis Style with Toe Filler $504.54 EachPF


False

No additions

O157Custom Foot Orthosis Style with Toe Filler and Sole Stiffener

$742.49 Each

PF


False

UPGRADE, No additions

O247Custom Silicone Prosthesis $2,682.00 EachPF


False

No additions

O197Enclosed Socket Style Prosthesis $1,609.00 EachPF



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###Upper Extremity Orthoses


###Shoulder and Shoulder-Elbow-Wrist-Hand Orthoses


Functional Arm Orthosis With Shoulder Cap

False

No Additions

O453 $2,109.73 EachSO

1 U/E Orthosis Per 2 Years

Highlander Shoulder Sling

FalseO447 $656.36 EachSO


Humeral Orthosis

FalseO449Custom Fitted $295.72 EachSO


FalseO451Molded to patient model $961.96 EachSO


###Elbow Orthoses


Elbow Orthosis

FalseO454Molded to patient - low temp thermoplastics $426.71 EachEO


FalseO456Molded to patient model $838.69 EachEO


Hinged Elbow Orthosis

FalseO455Molded to patient model $1,230.04 EachEO


###Wrist-Hand Orthoses - Dynamic


CTI2 Wrist Brace

FalseO140Custom - made from cast $1,512.42 EachWHO


FalseO153OTS Fit according to measurements $544.31 EachWHO


WHO

FalseO463Molded to patient model with joints $1,098.57 EachWHO


FalseO465Rancho, Engen or equivalent $1,663.01 EachWHO


###Wrist-Hand Orthoses - Static


WHO

FalseO466Custom Fitted, long opponens kit type $298.47 EachWHO


FalseO492Custom made, soft leather $983.73 EachWHO



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APL O-18

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###Wrist-Hand Orthoses - Static


WHO

FalseO462Molded to patient model, high temperature thermoplastics

$918.81 Each

WHO


FalseO490Static Molded to the patient model, working splint (wrist gauntlet)

$807.79 Each

WHO


###Hand Orthoses - cannot be added to WHO


Short Opponens

FalseO469Molded to patient model $564.34 EachWHO


Short Opponens Kit

FalseO464Custom Fitted - Rancho, Engen or equivalent $243.75 EachWHO


###Finger Orthoses

Generic Finger Orthosis

False

To control finger deformities. No Additions.

N305Functional Ring Splints $293.63 Max. EachWHO

1 Per Digit Per 2 Years

###Additions to Upper Extremity Othoses

Total limit of 10 additions per orthoses. No duplicate additions for the same digits or joint.

1st Dorsal Interosseous Assist

FalseO470 $154.22 EachWHO

10 U/E Additions Per 2 Years

Adjustable MP Flexion Control



Adjustable MP Flexion Control and IP Flexion Control



Adjustable Position Lock

FalseO460Contracture reduction $349.83 EachEO


FalseO461With Active Control $1,130.49 EachEO


Dynamic Elbow Extension Assist

False

To maintain/increase ROM chronic non-fixed flexion contractures. Must indicate criteria in E-Business Benefit Note.

O365 $761.40 EachEO



Page 20 of 26



APL O-19

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###Additions to Upper Extremity Othoses

Total limit of 10 additions per orthoses. No duplicate additions for the same digits or joint.

Figure 8 Harness and Bowden Cable

FalseO485 $259.00 EachEO


Flexion or Extension Assist



Flexion/Extension Assist

FalseO458 $237.25 EachEO


IP Ext. Assist



Lumbrical Bar



Metal Uniaxial Hinge with Adjustable Postion Lock

FalseO360Beckers 4001C/4001B $377.03 EachWHO


FalseO356Beckers Flexion or Extension Assist 4001C/4001B $377.03 EachWHO


MP Ext. Assist



MP Ext. Stop



Spring Swivel Thumb



Tamarack Hinge for Elbow

FalseO158Dorsiflexion assist or non-dorsiflexion assist $235.20 Per PairEO


Tamarack Hinge for Wrist

FalseO160Dorsiflexion assist or non-dorsiflexion assist $235.20 Per PairWHO


Thumb MP Stop With Thumb IP Ext. Assist



Thumb Post




Page 21 of 26



APL O-20

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eded

Qty. / Freq.

###Non-Rigid Musculoskeletal Supports


###Spinal Orthoses - Non-Rigid


Generic Dorso-Lumbar Support

FalseN7411st Fitting $338.68 Max. EachNRS

1 "1st Fitting" & 1 "2nd Support" Per 12 Months

FalseN3012nd Support - No Fitting Fee $161.68 Max. EachNRS


Generic Lumbo-Sacral Support

FalseN7441st Fitting $350.62 Max. EachNRS


FalseN3022nd Support - No Fitting Fee $173.62 Max. EachNRS


Lumbosacral Support

FalseO128Custom Made $362.84 EachNRS

1 Custom Made Support Per 12 Months

Sacroiliac Support


1 Support Per 12 Months

Thoraco-Lumbo-Sacral support



###Soft Support Additions

Bariatric Option for Soft Supports

FalseN746 $177.00 EachHERNIA, NRS

2 Additions Per 12 Months

###Hernia Supports


Generic Abdominal Hernia Support

FalseN7401st Fitting $281.56 Max. EachHERNIA


FalseN3062nd support - No Fitting Fee $104.56 Max. EachHERNIA


Generic Inguinal Hernia Support

FalseN7421st Fitting $237.70 Max. EachHERNIA


FalseN3072nd support - No Fitting Fee $60.70 Max. EachHERNIA



Page 22 of 26



APL O-21

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###Non-Rigid Musculoskeletal Supports


###Hernia Supports


Hernia Support Cloth/elastic Type

FalseO179Custom Made $597.55 EachHERNIA



Page 23 of 26



APL O-22

Supers

eded

Qty. / Freq.

###Orthotic Benefits for Clubfoot


###Orthotic Benefits for Clubfoot

Clubfoot benefits are part of AADL Orthotic Benefits, but are administered differently.

Eligibility Criteria:

Clients must meet all AADL general eligibility criteria.

Clients must be diagnosed with clubfoot and have an orthosis recommended by an orthopedic surgeon orspecialized clubfoot team.

In lieu of a prescription, Specialty Suppliers may obtain an "AADL Clubfoot Benefits Referral" form prior toassessing or providing benefits.

Clients are not eligible to be provided AADL Clubfoot Benefits and other lower extremity Orthotic Benefits at thesame time. For example, a client may not have a clubfoot brace and another AFO at the same time.

Clubfoot benefits are not eligible for repairs or modifications. The cost for any repairs or maintenance outside ofthe manufacturer's warranty are the client's responsibility.

Authorizations:

Clubfoot benefits are provided using an ongoing authorization which is active for five years from the initialassessment date.

Specialty Suppliers must select authorization type "CF" when creating the authorization on E-business.

Clients or Specialty Suppliers may contact AADL directly to request a vendor change for a clubfoot authorization.

Specialty Suppliers must contact AADL directly for clients who require benefits for longer than five years.

Assessment

False

Includes the assessment, measurement, and fitting of clubfoot AFOs and abduction bar.Only available to non-AHS vendors.

O750Complete Orthotic Assessment $132.75 Per Assessment

CF

3 Complete Assessments Per 5 Years

False

Includes the assessment, measurment and fitting of replacement components (AFOs or abduction bar).Only available to non-AHS vendors, if new measurements are taken by the vendor.

O753Follow-Up Assessment $70.80 Per Assessment

CF

10 Follow-Ups Per 5 Years

Generic Abduction Bar

FalseN751All sizes $111.32 Max. EachCF

3 Abduction Bars Per 5 Years

Generic AFOs/Boots

False

If only one boot required, maximum price is $170.86

N753All sizes $341.72 Max. Per Pair

CF

8 Pairs of AFOs/Boots Per 5 Years


Page 24 of 26



APL O-23

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###Orthotic Service Fees


###Orthotic Modifications and Repairs

AADL will not fund any modifications or repairs to an orthotic device within ninety (90) days of provision of the device. Specialty Suppliers are required to provide all necessary follow-up to ensure the device is able to be used for the purpose intended without additional cost to AADL or the client.

Replacement of components (joints, retention straps, etc.) must be authorized using the respective catalogue numbers listed in the approved product list. Do not use moditication or repair catalogue numbers for replacement.

Basic maintenance of an orthosis, for example cleaning of the device is the client's responsibility.

Specialty Supplier must document the nature of the work completed and the clinical justification in the E-business benefit notes for all authorized modications or repairs.

Adjustments

False

For adjustments due to a documented area of pressure or significant irritation.

O605Adjustment for Pressure Area $59.70 All except CF, HERNIA, NRS

3 Adjustsments Per 12 Months

False

For adjustments due to a change in the size or shape of the client's body.

O603Sizing/Fit Adjustment $59.70 All except CF, HERNIA, NRS

3 Adjustsments Per 12 Months

Orthotic Modification and Repairs

False

Eligible only if component will not be replaced for at least 6 months.

Fax the following information to AADL for prior approval:- Client information- Detailed description of the work to be done- Clinical justification- Cost breakdown, including all labour and materials

O609Major Modification or Repair Prior ApprovalAll except CF, HERNIA, NRS

3 Modifications/Repairs Per 12 Months

False

To maintain structural integrity and/or function orthosis.

O607Minor Modification or Repair $139.35 All except CF, HERNIA, NRS


False

Eligible only if component will not be replaced for at least 6 months.

Fax the following information to AADL for prior approval:- Client information- Detailed description of the work to be done- Clinical justification- Cost breakdown, including all labour and materials

O627Non-Warranty Repair by Manufacturer Prior ApprovalAll except CF, HERNIA, NRS


False

For commercial components only. Cannot be authorized for fit adjustments. Eligible only if component will not be replaced for at least 6 months. Includes: Removal and re-installation of the component.

O625Warranty Repair by Manufacturer $221.25 All except CF, HERNIA, NRS



Page 25 of 26



APL O-24

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###Orthotic Service Fees


###Orthotic Replacement Components

AADL will not fund any replacement components for an orthotic device for a minimum of ninety (90) days of provision of the device. Specialty Suppliers are required to provide all necessary follow-up to ensure the device is able to be used for the purpose intended without additional cost to AADL or the client.

The catalogue numbers listed below must only be used to replace a component on the client's most current orthosis. They cannot be used as part of an authorization for a new device, nor can they be used to authorize a duplicate or back-up components.

If the component to be replacement was origianlly authorized upsing a specific catalogue number (joints, retention straps, etc.), it must be authorized using that same original catalogue number.

Specialty Supplier must documents the nature of the work completed and the clinical justification in the E-business benefit notes for all authorized replacement components.

Replacement Liner

False

After 6 months

O495Cervical Orthosis $36.25 EachCO

1 Liner Per 12 Months

False

After 6 months

N708Generic Knee Orthosis Liner Kit $119.91 Max. EachKO

1 Set of Liners Per 12 Months

Replacement Parts for Milwaukee Orthosis

FalseO192Kyphosis pad $163.28 EachCTLSO

3 Replacement Parts Per 2 Years

FalseO194Lumbar pad $82.86 EachCTLSO


FalseO214Skirt $1,776.12 EachCTLSO


FalseO198Sternal pad $120.54 EachCTLSO


Replacement Straps

FalseO526Lower Extremity Strap - Lower Leg $33.15 EachAFO, HKAFO,

KAFO, KO, THKAFO

4 Lower Leg Straps Per 12 Months

False

Primarily used as part of a CFAB KO

N714Lower Extremity Strap - Specialized Knee Strap - Generic

$57.55 Max. Each

HKAFO, KAFO, KO, THKAFO

1 Knee Strap Per 12 Months

FalseO519Lower Extremity Strap - Upper Leg $33.15 EachHKAFO, KAFO, KO,

THKAFO

4 Upper Leg Straps Per 12 Months

FalseO529Spinal Orthosis Strap $33.15 EachCO, CTLSO, LSO,

TLSO

4 Spinal Straps Per 12 Months

FalseO528Upper Extremity Strap $33.15 EachEO, SO, WHO

8 U/E Straps Per 12 Months


Page 26 of 26



APL O-25

Supers

eded

Documents

Alberta Health Superseded · Custom made from cast O215False $1,825.04 Each TLSO 1 Spinal Orthosis Per 2 Years Custom made from measurement O506False $1,348.27 Each TLSO 1 Spinal