Alberta Health AADL Approved Product List - Orthotic Benefits
Alberta Health AADL Approved Product List - Orthotic Benefits Pricing effective April 1, 2014 © 2013 Government of Alberta April 1, 2014 Alberta Health - Professional Services and Health Benefits AADL Manual O - Orthotics Approved Product List General Information Functional Outcomes 100 Restrict range of motion of a joint to reduce/prevent the need for surgical or medical treatment 101 Restrict range of motion of a joint to reduce/control tone or spasticity 102 Control spinal deformity (e.g., scoliosis) 103 Protection of a body part (e.g., helmet) 104 Improve function by providing stability of the joint 105 Improve function by positioning body part for activities of daily living 106 Improve function by assisting muscle weakness 107 Improve function by enabling lying, sitting, and standing (likely the more disabled client) 108 Improve function by enabling walking and/or increased walking efficiency/endurance 109 Facilitate healing of a body part 110 Reduce pain (e.g., arthritis-related) 111 Support soft tissue (e.g., hernia) 112 Repairs Generic Pricing Procedure Use the AADL Generic Calculator to determine the AADL price for a generic catalogue number. Procedure 1. Enter the catalogue number and verify the product description is correct. 2. 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. 3. Enter manufacturer name and part number as indicated. 4. Copy and paste the calculation into the Benefit Note on E-Business. 5. Costs over the indicated maxmimum are indicated in the calculator and are considered an upgrade. © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 APL O-1Page 2 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Spinal Orthoses Qty. / Freq. Cat. No. AADL Price ### Cervical Spine Procedures Physician Prescription Required C.O. 1 CO Per 2 Years 2 or 4 poster C.O. designs - custom fitted, e.g. U.S.M.C. or equivalent O092 $428.61 Each Aspen O098 $244.14 Each Custom Made - Molded to patient model, cervical and thoracic control (Minerva type) O166 $2,653.84 Each Custom Made - molded to patient model, cervical and thoracic control (Minerva type) plus interface O168 $2,671.59 Each Molded to patient model O088 $897.57 Each Prefabricated C.O. which requires custom fitting (e.g. Philadelphia or thermoplastic designs or equivalent) O084 $258.56 Each With cervical and upper thoracic control, custom fitted(e.g. S.O.M.I. vest or equivalent) O091 $817.03 Each With occipital/mandibular supports with thoracic extensionsfor increased cervical control, custom-fitted (e.g. S.O.M.I., Fi-way, La-cal, Guilford or equivalent) O090 $391.76 Each O495 $75.73 Each O300 $408.83 Each Cervical Orthosis Replacement Liner 1 Liner Per 12 Months After 6 months Hensinger Head Support 1 Head Support Per 2 Years ### Thoracic Orthoses Pectus Brace 1 Thoracic Brace Per 2 Years O342 $1,131.59 Each ### Spinal Orthosis - Rigid - Anterior Control Physician Prescription Required Cruciform Hyperextension Orthosis Custom Fitted (Cash or equivalent) 1 Spinal Orthosis Per 2 Years Hyperextension orthosis Custom Fitted (Jewitt or equivalent) 1 Spinal Orthosis Per 2 Years Custom Made O119 $608.80 Each O117 $651.66 Each O121 $1,532.84 Each ### Spinal Orthosis - Rigid - Antero-Posterior Control Physician Prescription Required California ECO Spinal Orthosis 1 Spinal Orthosis Per 2 Years O193 © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 $591.01 Each APL O-2Page 3 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Spinal Orthoses Qty. / Freq. Cat. No. AADL Price ### Spinal Orthosis - Rigid - Antero-Posterior Control Physician Prescription Required Knight Orthosis or Equivalent Custom Fitted (no lat. Uprights) 1 Spinal Orthosis Per 2 Years Taylor Orthosis or Equivalent Custom Fitted 1 Spinal Orthosis Per 2 Years Custom Made O101 $453.26 Each O100 $540.19 Each O103 $1,136.84 Each ### Spinal Orthosis - Rigid - Antero-Posterior and Lateral Control Physician Prescription Required 1 Spinal Orthosis Per 2 Years Knight Orthosis Custom Fitted (Kydex or equivalent thermplastic design) O131 $475.66 Each O130 $507.02 Each O135 $1,404.14 Each O106 $493.58 Each O105 $453.26 Each No additions Knight Orthosis or Equivalent Custom Fitted (conventional design) 1 Spinal Orthosis Per 2 Years Custom Made (conventional design) 1 Spinal Orthosis Per 2 Years Taylor-Knight Orthosis Custom Fitted (Kydex chairback or equivalent thermoplastic design) No additions Taylor-Knight Orthosis or Equivalent Custom Fitted (conventional design) 1 Spinal Orthosis Per 2 Years ### Spinal Orthosis - Rigid - Postero-Lateral Control Physician Prescription Required Williams flexion orthosis Custom Made 1 Spinal Orthosis Per 2 Years O145 $1,639.27 Each No addition ### Additions to Rigid Spinal Orthoses Not for Kydex orthoses O120, O131, O106, or Williams orthosis O145. Bariatric Option 1 Bariatric Option Per 2 Years O497 $233.00 Each O150 $178.98 Each O152 $134.73 Each O148 $167.11 Each Client is 100 lb. over normal weight or over 275 lb. Must indicated criteria in EBusiness Benefit Note. Corset front As opposed to apron front 1 Addition Per 2 Years Full corset As opposed to apron front 1 Addition Per 2 Years Sub-Clavicular Extensions For rotary control 1 Addition Per 2 Years © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 APL O-3Page 4 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Spinal Orthoses Qty. / Freq. Cat. No. AADL Price ### Total Contact T.L.S.O. (Body Jacket) Physician Prescription Required 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. Must indicate clinical rationale in E-Business Benefit Note. Boston Jacket Custom made from cast 1 Spinal Orthosis Per 2 Years O215 $1,736.54 Each Custom made from measurement O506 $1,259.77 Each Soft - Stock O505 $1,198.73 Each O213 $1,762.89 Each Custom from measurement O211 $1,666.67 Each Stock custom fitted O218 $1,677.87 Each O219 $1,292.60 Each O123 $2,379.77 Each Molded antero-posterior design with interface O125 $2,525.12 Each Molded to patient model O122 $2,246.20 Each Molded to patient model with interface O124 $2,391.73 Each Posterior, Anterior shell only with corset or equivalent front O127 $1,789.90 Each Scoliosis procedure - Molded to patient model with interface O220 $2,571.68 Each Boston Orthosis Custom from cast 1 Spinal Orthosis Per 2 Years Boston Overlap Orthosis or Equivalent Molded to patient 1 Spinal Orthosis Per 2 Years T.L.S.O. Molded antero-posterior design 1 Spinal Orthosis Per 2 Years ### C.T.L.S.O. - Milwaukee Physician Prescription Required Complete Milwaukee Orthosis Initial 1 Spinal Orthosis Per 2 Years O188 $3,284.44 Each Kyphosis pad O192 $163.28 Each Lumbar pad O194 $82.86 Each Sternal pad O198 $120.54 Each O214 $1,776.12 Each No additions Replacement Parts for Milwaukee Orthosis Skirt Replacement only, molded to patient model © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 3 Replacement Parts Per 2 Years 1 Per 2 Years APL O-4Page 5 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Spinal Orthoses Qty. / Freq. Cat. No. AADL Price ### Helmet Criteria Must be required for daily use 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. 1 Helmet Per 2 Years Custom Fitted Helmet A modular helmet system requiring measurement, modification of modular parts and assembly, based on DANMAR helmet. O051 $1,184.32 Each O053 $1,494.39 Each Orthotist must in E-Business Benefit Note indicate why commercial (e.g. bicycle, mountain climbing, etc.) helmets are inadequate. 1 Helmet Per 2 Years Helmet Molded to Patient Model. Helmet made with high temperature hermoplastic with liner. Orthotist must in E-Business Benefit Note indicate why commercial (e.g. bicycle, mountain climbing, etc.) helmets are inadequate. © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 APL O-5Page 6 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Lower Extremity Orthoses Qty. / Freq. Cat. No. AADL Price ### Hip Abduction Control Physician Prescription Required Dennis Brown Plate 1 Hip Abduction Control Orthosis Per 2 Years O306 $224.17 Each O241 $2,134.39 Each O235 $722.85 Each Custom Fitted (Von Rosen or equivalent) O237 $366.24 Each Custom Made (Von Rosen or equivalent) O238 $748.10 Each O233 $545.85 Each 1 Hip Abduction Control Orthosis Per 2 Years Pelvic control, adjustable hip motion control, thigh cuffs (Rancho Hip Action Design) Dynamic Brace Static Adjustable 1 Hip Abduction Control Orthosis Per 2 Years Custom Fitted (Ilfield design) Static Foam or Thermoplastic Design Static Pelvic Band or Spreader Bar 1 Hip Abduction Control Orthosis Per 2 Years 1 Hip Abduction Control Orthosis Per 2 Years Custom Fitted - with thigh cuffs ### Torsion Control Physician Prescription Required Pelvic Band/Belt With bilateral rotation straps 1 Pelvic Band/Belt Per 2 Years O294 $519.99 Each With torsion cables and ball bearing hip joints, bilateral cable usage O298 $1,261.84 Each With torsion cables and ball bearing hip joints, unilateral cable usage hip joints, unilateral cable usage O297 $868.79 Each ### Abduction and Rotation Control Physician Prescription Required Atlanta or Scottish-Rite Trilateral Orthosis SWASH © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 1 Hip Abduction Control Orthosis Per 2 Years O305 $2,107.68 Each O242 $1,835.04 Each 1 Per 2 Years APL O-6Page 7 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Lower Extremity Orthoses Qty. / Freq. Cat. No. AADL Price ### Knee Hyperextension Orthoses Physician Prescription Required Criteria Required for 6 months and longer, for full-time activities of daily living and/or full-time activities at work. Full-time is defined as a minimum of 6 hours per day, every day. Must indicate clinicial condition in E-Business Benefit Note. Camp CHECK Custom fit hyperextension control knee orthosis 1 KO Per 4 Years Swedish Knee Orthosis Standard 1 KO Per 4 Years With hinge O317 $804.65 Each O253 $274.08 Each O260 $392.63 Each ### Knee Orthosis to Prevent Knee Flexion Physician Prescription Required Criteria Required for 6 months and longer, for full-time activities of daily living and/or full-time activities at work. Full-time is defined as a minimum of 6 hours per day, every day. Must indicate clinical condition in E-Business Benefit Notes (example: failed knee replacement or knee fusion). Prescriber must be one of the following specialist physicians: orthopedics, physiatry, rheumatology, geriatrics. Total Contact Cylinder Orthosis High temp. thermoplastics, molded to patient model 1 KO Per 4 Years Low temp. thermoplastics, molded directly to patient O257 $1,024.40 Each O256 $559.70 Each ### 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 for serial 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 1 KO Per 4 Years O550 $842.65 Each ### Knee Joints for Custom Made Knee Orthosis or KAFO Adjustible Extension Ring Lock Becker 1006 1 Per Upright Per 2 Years Automatic Spring Lever Becker 1003 1 Per Upright Per 2 Years Generic Knee Joint 2 Knee Joints Per 2 Years O391 $349.84 Each O379 $322.31 Each N699 $468.58 Max. Each See generic pricing procedure © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 APL O-7Page 8 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Lower Extremity Orthoses Qty. / Freq. Cat. No. AADL Price ### Knee Joints for Custom Made Knee Orthosis or KAFO Generic Knee Joint - For One Joint 2 Knee Joints Per 2 Years N303 $468.50 Max. Each For generic custom made stabilizing knee brace for failed total knee replacements, neurological deficits (defined by prescription), quadriceps weakness, knee extension greater than 10 degrees where no neurological condition exists (patellectomy). See Generic Pricing Procedure ### 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 haave 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 or severe 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 document in the EBusiness 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 of $1610.12. Total price of the knee brace requires a procedure price and a knee brace price. "Upgrade" indicates a product whose cost exceeds the AADL maximum contribution, any additional cost is a client's choice and responsibility. CFAB (Custom) Unloading Knee Orthosis Bregg Fusion OA Custom 1 KO Per 4 Years O110 $993.95 Each Generation II Unloader XT O531 $957.91 Each Generic CFAB (Custom) - Canadian Origin N730 $957.91 Max. Each N732 $909.95 Max. Each O554 $812.31 Each O556 $446.48 Each N710 $769.04 Max. Each See generic pricing procedure Generic CFAB (Custom) - US Origin See generic pricing procedure Neutralizer Custom Fit (OTS) Unloading Knee Orthosis Generation EXPRESS 1 KO Per 4 Years Client must meet the same OA criteria that is required for custom made knee brace. Generic Custom Fit (OTS) - Canadian Origin See generic pricing procedure © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 APL O-8Page 9 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Lower Extremity Orthoses Qty. / Freq. Cat. No. AADL Price ### 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 haave 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 or severe 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 document in the EBusiness 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 of $1610.12. Total price of the knee brace requires a procedure price and a knee brace price. "Upgrade" indicates a product whose cost exceeds the AADL maximum contribution, any additional cost is a client's choice and responsibility. Custom Fit (OTS) Unloading Knee Orthosis Generic Custom Fit (OTS) - US Origin 1 KO Per 4 Years N712 $959.19 Max. Each O191 $499.12 Each O537 $1,214.77 Each O259 $851.40 Each O551 $652.19 Each In-House Custom Procedure O501 $652.19 Each Presized OA O565 $354.00 Each See generic pricing procedure Ossur - Unloader One - Off the shelf In-House (Custom) Unloading Knee Orthosis Laminate 1 KO Per 4 Years Procedure and joints to be added Plastic Procedure and joints to be added Unloading Knee Orthosis Procedure CFAB (Custom) 1 KO Procedure Per 4 Years ### Locking Function Addition to Unloading Knee Orthosis Must indicated clinical rationale for addition in E-Business Benefit Note, i.e. increased stabilization of stabilizing knee orthosis, for SEVERE instability of knee. Locking Knee Hinge(s) or Equivalent 1 Per Side Per 4 Years O477 © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 $285.56 Each Page APL O-9 10 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Lower Extremity Orthoses Qty. / Freq. Cat. No. AADL Price ### Locking Function Addition to Stabilizing Knee Orthosis Must indicated clinical rationale for addition in E-Business Benefit Note, i.e. increased stabilization of stabilizing knee orthosis, for SEVERE instability of knee. Locking Knee Hinge(s) 1 Per Side Per 4 Years O479 $285.56 Each ### 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 EBusiness Benefit Note. Orthopedic Criteria Must 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 or an 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 designated with a special interest in Sports Medicine by the College of Physicians & Surgeons of Alberta. Neurological Criteria A 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 of $1487.87. Total price of the knee brace requires procedure price and a knee brace price.“Upgrade” indicates a product whose cost exceeds the AADL maximum contribution, any additional cost is a client’s choice and responsibility. CFAB (Custom) Knee Orthosis Generation II Extreme or Custom Paradigm 1 KO Per 4 Years Generic CFAB (Custom) - Canadian Origin O538 $889.59 Each N700 $1,010.55 Max. Each N701 $909.95 Max. Each O548 $922.27 Each N722 $660.00 Max. Each N720 $519.72 Max. Each See generic pricing procedure Generic CFAB (Custom) - US Origin See generic pricing procedure Innovation CTI 2 Custom Fit (OTS) Stabilizing Knee Orthosis Generic Custom Fit (OTS) - US Origin 1 KO Per 4 Years See generic pricing procedure Generic Custom Fit (OTS) - Canadian Origin See generic pricing procedure © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 Page APL O-10 11 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Lower Extremity Orthoses Qty. / Freq. Cat. No. AADL Price ### 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 EBusiness Benefit Note. Orthopedic Criteria Must 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 or an 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 designated with a special interest in Sports Medicine by the College of Physicians & Surgeons of Alberta. Neurological Criteria A 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 of $1487.87. Total price of the knee brace requires procedure price and a knee brace price.“Upgrade” indicates a product whose cost exceeds the AADL maximum contribution, any additional cost is a client’s choice and responsibility. Custom Fit (OTS) Stabilizing Knee Orthosis GII Paradigm 1 KO Per 4 Years O340 $562.96 Each O558 $456.76 Each O546 $1,214.77 Each N304 $1,214.77 Max. Each O545 $851.40 Each CFAB Custom O570 $563.69 Each Custom Fit (OTS) O571 $354.00 Each Innovations Sport - C180 Client must meet the same knee instability criteria that is required for custom made knee brace. In-House Custom Stabilizing Knee Orthosis Laminate 1 KO Per 4 Years Procedure and Joints to be added Laminate or Plastic For failed total knee replacements, neurological deficits (defined by prescription) quadriceps weakness, knee extension greater than 10 degrees where no neurological condition exists (patellectomy). Procedure and Joints to be added. See generic pricing procedure. Plastic Procedure and joints to be added Stabilizing Knee Orthosis Procedure © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 1 Orthotic Procedure Per 4 Years Page APL O-11 12 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Lower Extremity Orthoses Qty. / Freq. Cat. No. AADL Price ### 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 EBusiness Benefit Note. Orthopedic Criteria Must 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 or an 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 designated with a special interest in Sports Medicine by the College of Physicians & Surgeons of Alberta. Neurological Criteria A 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 of $1487.87. Total price of the knee brace requires procedure price and a knee brace price.“Upgrade” indicates a product whose cost exceeds the AADL maximum contribution, any additional cost is a client’s choice and responsibility. Stabilizing Knee Orthosis Procedure 1 Orthotic Procedure Per 4 Years In-House Custom O507 $563.69 Each ### Ankle Foot Orthoses Physician Prescription Required 1 AFO Per 2 Years AFO Anterior Floor Reaction O288 $1,343.48 Each Composite plastic molded to patient model layered lamination/carbon fibre O265 $2,217.38 Each O602 $2,372.98 Each O578 $1,703.93 Each Check socket should be used. Criteria - Severe deformity and greater than or equal to 200 lbs. and rotational stability required. Must indicate criteria in EBusiness Benefit Note. CROWE Walkers (Bivalved AFO lined with Rocker Sole) Criteria: Charcot Ankle Joint. Criteria must be inticated in E-Busniess Benefit Note. Clients cannot have custom made footwear and a CROWE walker. Energy Storing/Return Ankle Foot Orthosis Active community ambulator, plantar flexion weakness, quads good. Must indicate criteria in E-Business Benefit Note. © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 Page APL O-12 13 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Lower Extremity Orthoses Qty. / Freq. Cat. No. AADL Price ### Ankle Foot Orthoses Physician Prescription Required 1 AFO Per 2 Years AFO Generic Pre-Fab N280 $1,148.93 Max. Each Molded to patient model, articulating O286 $1,299.23 Each Supra malleolar - High temperature thermoplastic molded to patient model. O155 $1,010.84 Each N309 $424.28 Each O280 $771.27 Each O278 $638.52 Each E601 $297.90 Each O270 $328.02 Each Custom made to patient model O272 $1,249.68 Each Rigid - double form O369 $1,654.66 Each O277 $1,962.98 Each O275 $1,962.98 Each See generic pricing procedures 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. Check for AFO 1 Check AFO Per 2 Years 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. Conventional AFO With double uprights, calf band and free ankle 1 AFO Per 2 Years With single upright, calf band and free ankle Night Splints for Neuromuscular Peds 1 Per 2 Years Client not eligible for day and night AFO. Definitive brace policy confirmed with Physician. If KAFO required within 1 year, cost of AFO deducted. Polypropylene AFO Custom fittied PTB AFO Plastic molded to patient model Ant/Post shell 1 AFO Per 2 Years 1 AFO Per 2 Years Prosthetic BK type socket molded to patient model with double uprights and free ankles (PTB AFO) ### Additions to Ankle Foot Orthoses Ankle Joints Dorsiflexion Assist 1 Pair Per 2 Years O310 $248.28 Per Pair Double Action O312 $284.57 Each Limited Motion O308 $223.25 Per Pair If only single joint claim for 1/2 of price maximum. © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 Page APL O-13 14 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Lower Extremity Orthoses Qty. / Freq. Cat. No. AADL Price ### Additions to Ankle Foot Orthoses Bariatric Option 1 Bariatric Option Per 2 Years O499 $233.00 Each O319 $399.36 Each O577 $289.05 Each O335 $47.40 Each O318 $743.68 Each O309 $435.85 Each O316 $288.32 Each O314 $280.43 Each O322 $208.46 Each Client is 100 lb. over normal weight or over 275 lb. Must indicated criteria in EBusiness Benefit Note. Calf Band Custom molded to patient model 1 Per 2 Years Custom Fabricated Flexible Interface 1 Per 2 Years Criteria: For unstable, high tone, or severe foot deformity. Criteria must be indicated in E-Busniess Benefit Note. 1 Per 2 Years Dorsal Ankle Strap (retention) High extensor tone requires additional strap. Must indicate criteria in EBusiness Benefit Note. 1 Per 2 Years Molded Foot Section Attached to Stirrup Pre-Tibial Shell Removeable or fabricated into rigid AFO 1 Per 2 Years Round Caliper Plate 2 Per 2 Years 2 Per 2 Years Stirrup Spilt stirrup and flat caliper plate or solid sturrip Valgus or Varus "T" Straps 2 Years Per 2 Years Quantity Limit: 1 per 2 years, except 2/2 years with O314, O316, O320 ### Articulated Ankle Foot Orthoses Physician Prescription Required 1 AFO Per 2 Years Polypropylene Articulating AFO Custom made to patient model (single form) base price Double form O325 $1,254.98 Each O323 $1,721.16 Each ### Additions to Articulating AFOs - O323 and O325 Becker Tamarack Ankle Joints Dorsiflexion Assist/Non-Dorsiflexion Assist Dorsi Flexion Stop Custom Gaffney Joints © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 1 Pair Per 2 Years O311 $313.71 Pair O329 $293.50 Each O333 $329.72 Per Pair 1 Per 2 Years 1 Pair Per 2 Years Page APL O-14 15 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Lower Extremity Orthoses Qty. / Freq. Cat. No. AADL Price ### Additions to Articulating AFOs - O323 and O325 Generic Ankle Joints 1 Pair Per 2 Years N300 $410.92 Max. Per Pair O327 $161.75 Each See generic pricing procedure Plantar Flexion Stop Custom 1 Per 2 Years ### Knee Ankle Foot Orthoses (KAFO) Physician Prescription Required Joint to be added. Knee joints listed before knee orthoses. Please refer back to that section of the schedule. Check for KAFO 1 Check KAFO Per 2 Years N310 $626.73 Each O283 $1,510.16 Each Double upright O287 $1,909.63 Each Single upright without knee joint O285 $1,510.16 O299 $3,710.78 Each O293 $2,566.32 Each O292 $2,273.83 Each O291 $2,566.32 Each O290 $2,063.31 Each 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. Conventional KAFO Conventional single upright 1 KAFO Per 2 Years Graphite KAFO Double upright 1 KAFO Per 2 Years Hybrid KAFO Double upright 1 KAFO Per 2 Years Single upright KAFO Double upright, plastic Single upright, plastic © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 1 KAFO Per 2 Years Page APL O-15 16 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Lower Extremity Orthoses Qty. / Freq. Cat. No. AADL Price ### Stance Phase KAFO Physician Prescription Required 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 Criteria must be indicated in E-Business Benefit Note. Any comparable quality system to below listed items may be substituted with AADL prior approval. Stance Phase KAFO Free Walk Ottobock 1 KAFO Per 2 Years UTX Becker O232 $4,354.54 Each O230 $3,450.50 Each ### Additions to KAFO and Knee Joints 1 Pair Per 2 Years Bail Locks Bar or Equivalent O343 $352.95 Per Pair O498 $466.00 Each O184 $339.32 Each O334 $525.28 Each O330 $239.99 Each O345 $449.14 Per Pair O341 $212.36 Per Pair O388 $222.92 Each 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 joint. If only a single hinge/lock claim for 1/2 of price max. Bariatric Option 1 Bariatric Option Per 2 Years Client is 100 lb. over normal weight or over 275 lb. Must indicated criteria in EBusiness Benefit Note. Becker Cable Control for Trigger Lock MX003-HS/R 1 Per 2 Years Calf Lacer Full, molded to patient model 1 Per 2 Years Half, non-molded Disc or Dial Lock Joints for Adjustable Knee or Equivalent 1 Pair Per 2 Years If only a single hinge/lock claim for 1/2 of price maximum Drop Lock or Equivalent 1 Pair Per 2 Years 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 Extension for Lineal Adjustment for Growth for Side Bars © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 1 Per 2 Years Page APL O-16 17 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Lower Extremity Orthoses Qty. / Freq. Cat. No. AADL Price ### Additions to KAFO and Knee Joints Free Motion/Ring Lock Becker - 1002/1005/1008 1 Per Upright Per 2 Years Ottobock 17B43 Gluteal Pad 1 Per 2 Years Ischial Ring 1 Per 2 Years Offset Bail Locks 17B33 or Equivalent Offset Drop Locks 17B20 or Equivalent Pelvic Band, Belt and Bilateral Hip Joint Pelvic Band, Belt and Unilateral Hip Joint Polycentric Becker $232.78 Each O386 $148.93 Each O381 $655.63 Each O366 $618.59 Each O363 $135.90 Per Pair O352 $349.26 Each O350 $242.85 Each O384 $1,696.74 Each O382 $1,094.03 Each O377 $336.41 Each O371 $357.10 Each O336 $705.51 Each O359 $510.59 Each O368 $867.99 Each O399 $342.90 Each O387 Prior Approval O357 $420.09 Each 1 Per Upright Per 2 Years 1 Per Upright Per 2 Years 1 Per 2 Years 1 Per 2 Years 1 Per Upright Per 2 Years Pre-Tibial / Femoral Shell Molded to patient model 1 Per 2 Years Pull Over Knee Cage 1 Per 2 Years Rachet Lock Becker O373 1 Pair Per 2 Years Ottobock 17B46 Quadrilateral Brim Molded to patient model $318.46 Each 1 Per 2 Years Hip Joint Clevis type or thrust bearing, free Joint Covers O375 1 Per 2 Years 1 Per Upright Per 2 Years 1 Per 2 Years RGO (Reciprocating Gait Orthosis) Pelvic assembly and jacket only, does not include KAFO's. Contact AADL for prior approval of price. Standard Knee Cage © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 1 Per 2 Years Page APL O-17 18 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Lower Extremity Orthoses Qty. / Freq. Cat. No. AADL Price ### Additions to KAFO and Knee Joints 1 Per Upright Per 2 Step Loc OTS Corp O401 $380.58 Each O358 $183.91 Each O380 $382.32 Each O374 $620.28 Each Full, non-molded O372 $422.36 Each Half, custom made O376 $365.09 Each 1 Per 2 Years Sub Patellar Pad Swiss Lock Ottobock 17B36/17B48 1 Per Upright Per 2 Years 1 Per 2 Years Thigh Lacer Full, molded to patient model ### Stance Phase Knee Joint Physician Prescription Required 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 Criteria must be indicated in E-Business Benefit Note. Any comparable quality system to below listed items may be substituted with AADL prior approval. 1 Joint Per 2 Years Becker Load Response O240 $1,219.36 Each O243 $1,585.88 Each O263 $3,182.72 Each 2 Joints Per 2 Years Horton Stance Phase 1 Joint Per 2 Years Stance Phase Knee Joint - Fillauer Swing Phase Lock ### Thoracic-Hip-Knee-Ankle Orthoses Physician Prescription Required Any comparable quality system to below listed items may be substituted with AADL prior approval. Parapodium Small/large (Variety Village style) 1 Standing Frame Per 2 Years Recycle fee 1 Recycle Fee Per Limb Per 4 Years O224 $2,600.25 Each O517 25% of list of: O224, O226, O227, O222, O302, O242 © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 Page APL O-18 19 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Lower Extremity Orthoses Qty. / Freq. Cat. No. AADL Price ### Thoracic-Hip-Knee-Ankle Orthoses Physician Prescription Required Any comparable quality system to below listed items may be substituted with AADL prior approval. Standing Frame Custom fitted (Variety Village style) 1 Standing Frame Per 2 Years Custom Made Winnipeg Standing Frame O226 $1,695.23 Each O227 $2,344.47 Each O222 $2,273.70 Each 1 Standing Frame Per 2 Years ### Additions to Footwear Transfer Of Caliper Plate From Shoe To Shoe Transfer of Dennis Brown Foot Plates To New Shoes Transfer Of Solid Stirrup From Shoe To Shoe 2 Transfers Per 2 Years O442 $355.90 Each O446 $181.22 Each O444 $444.40 Each 2 Transfers Per 2 Years 2 Transfers Per 2 Years ### Partial Foot Prostheses Physician Prescription Required Partial Foot Prosthesis 1 Partial Foot Prosthesis Per 2 Years O516 Prior Approval Prior Approval. Fax the name of the client, PHN, description of the procedure, cost of materials and hours to fabricate the partial foot prosthesis. When approved by the AADL Manager, create the authorization on E-Business. © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 Page APL O-19 20 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Upper Extremity Orthoses Qty. / Freq. Cat. No. AADL Price ### Shoulder and Shoulder-Elbow-Wrist-Hand Orthoses Physician Prescription Required Functional Arm Orthosis With Shoulder Cap 1 Orthosis Per 2 Years O453 $2,109.73 Each O447 $363.76 Each O449 $430.72 Each O451 $961.96 Each No Additions Highlander Shoulder Sling Humeral Orthosis Custom Fitted 1 Shoulder Orthosis Per 2 Years 1 Humeral Orthosis Per 2 Years Molded to patient model ### Elbow Orthoses Physician Prescription Required Elbow Orthosis Molded to patient - low temp thermoplastics 1 Elbow Orthosis Per 2 Years Molded to patient model Hinged Elbow Orthosis Molded to patient model O454 $426.71 Each O456 $838.69 Each O455 $1,230.04 Each 1 Elbow Orthosis Per 2 Years ### Additions to Elbow Orthosis Adjustable Position Lock Contracture reduction 1 Per 2 Years With Active Control Dynamic Elbow Extension Assist O460 $349.83 Each O461 $1,130.49 Each O365 $842.65 Each O458 $237.25 Each O360 $326.48 Each O158 $313.88 Per Pair 1 Per 2 Years To maintain/increase ROM chronic non-fixed flexion contractures. Must indicated criteria in E-Business Benefit Note. Flexion/Extension Assist 1 Per 2 Years Metal Uniaxial Hinge with Adjustable Postion Lock Beckers 4001C/4001B 1 Per Joint Per 2 Years Tamarack Hinge for Elbow Dorsiflexion assist or non-dorsiflexion assist 1 Per 2 Years ### Wrist-Hand Orthoses - Dynamic Physician Prescription Required CTI2 Wrist Brace Custom - made from cast © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 1 WHO Per 2 Years O140 $1,512.42 Each Page APL O-20 21 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Upper Extremity Orthoses Qty. / Freq. Cat. No. AADL Price ### Wrist-Hand Orthoses - Dynamic Physician Prescription Required CTI2 Wrist Brace OTS Fit according to measurements 1 WHO Per 2 Years WHO Molded to patient model with joints 1 WHO Per 2 Years Rancho, Engen or equivalent O153 $544.31 Each O463 $1,098.57 Each O465 $1,663.01 Each ### Additions to the Dynamic WHO 1 Per 2 Years Figure 8 Harness and Bowden Cable $259.00 Each O484 $205.69 Each O356 $294.92 Each O160 $313.88 Per Pair 1 Per 2 Years Flexion or Extension Assist Metal Uniaxial Hinge with Adjustable Postion Lock Beckers Flexion or Extension Assist 4001C/4001B O485 1 Per Joint Per 2 Years 1 Per 2 Years Tamarack Hinge for Wrist Dorsiflexion assist or non-dorsiflexion assist ### Wrist-Hand Orthoses - Static Physician Prescription Required WHO Custom Fitted, long opponens kit type 1 WHO Per 2 Years O466 $535.00 Each Custom made, soft leather O492 $983.73 Each Molded to patient model, high temperature thermoplastics O462 $918.81 Each Static Molded to the patient model, working splint (wrist gauntlet) O490 $807.79 Each ### Hand Orthoses - cannot be added to WHO Physician Prescription Required Short Opponens Molded to patient model 1 HO Per 2 Years Short Opponens Kit Custom Fitted - Rancho, Engen or equivalent 1 HO Per 2 Years O469 $564.34 Each O464 $590.62 Each ### Additions to WHO (Static) and HO 1st Dorsal Interosseous Assist Adjustable MP Flexion Control © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 1 Per 2 Years O470 $154.22 Each O486 $302.85 Each 1 Per 2 Years Page APL O-21 22 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Upper Extremity Orthoses Qty. / Freq. Cat. No. AADL Price ### Additions to WHO (Static) and HO Adjustable MP Flexion Control and IP Flexion Control IP Ext. Assist Lumbrical Bar MP Ext. Assist MP Ext. Stop Spring Swivel Thumb Thumb MP Stop With Thumb IP Ext. Assist Thumb Post 1 Per 2 Years O488 $347.10 Each O472 $65.77 Each O473 $182.65 Each O476 $65.77 Each O474 $94.15 Each O480 $214.52 Each O482 $211.68 Each O471 $101.42 Each 1 Per Digit Per 2 Years 1 Per 2 Years 1 Per Digit Per 2 Years 1 Per Digit Per 2 Years 1 Per 2 Years 1 Per 2 Years 1 Per 2 Years ### Finger Orthoses Generic Finger Orthosis Functional Ring Splints 1 Per Digit Per 2 Years N305 $514.88 Max. Each To control finger deformities - see generic pricing procedure. © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 Page APL O-22 23 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Non-Rigid Musculoskeletal Supports Qty. / Freq. Cat. No. AADL Price ### Spinal Orthoses - Non-Rigid Physician Prescription Required Generic Dorso-Lumbar Support 1 "1st Fitting" & 1 "2nd Support" Per 12 Months 1st Fitting N741 $338.68 Max. Each N301 $161.68 Max. Each N744 $350.62 Max. Each N302 $173.62 Max. Each O128 $362.84 Each O156 $567.28 Each O097 $554.81 Each See generic pricing procedure 2nd Support - No Fitting Fee See generic pricing procedure Generic Lumbo-Sacral Support 1 "1st Fitting" & 1 "2nd Support" Per 12 Months 1st Fitting See generic pricing procedure 2nd Support - No Fitting Fee See generic pricing procedure Lumbosacral Support 1 Custom Made Support Per 12 Months Custom Made Sacroiliac Support Custom Made Thoraco-Lumbo-Sacral support 1 Support Per 12 Months 1 Custom Made Support Per 12 Months Custom Made ### Soft Support Additions Bariatric Option for Soft Supports 2 Additions Per 12 Months N746 $177.00 Each ### Hernia Supports Physician Prescription Required Generic Abdominal Hernia Support 1 "1st Fitting" & 1 "2nd Support" Per 12 Months 1st Fitting N740 $281.56 Max. Each N306 $104.56 Max. Each N742 $237.70 Max. Each N307 $60.70 Max. Each See generic pricing procedure 2nd support - No Fitting Fee See generic pricing procedure Generic Inguinal Hernia Support 1st Fitting 1 "1st Fitting" & 1 "2nd Support" Per 12 Months See generic pricing procedure 2nd support - No Fitting Fee See generic pricing procedure © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 Page APL O-23 24 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Non-Rigid Musculoskeletal Supports Qty. / Freq. Cat. No. AADL Price ### Hernia Supports Physician Prescription Required Hernia Support Cloth/elastic Type Custom Made © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 1 Custom Made Support Per 12 Months O179 $597.55 Each Page APL O-24 25 of 26 Alberta- Health - Professional Services and Health Benefits Benefits Alberta Health Professional Services and Health AADL Manual O - Orthotics Approved Product List Alberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits ### Orthotic Service Fees Qty. / Freq. Cat. No. AADL Price ### Other Fees Consult with Client and Multidisciplinary team 4 Consults Per 12 Months O403 $177.00 Per Hour O405 $177.00 Per Hour Maximum four consults per year. Maximum one hour per client at $177.00. Available to private orthotic facilities only. See Policy & Procedures for eligibility criteria. Off-Site Facility Fee 1 Fee Per 12 Months Maximum one hour per client per year at $177.00 per hour. Invoice for only one off site fee/per client/per device. Available to all orthotic facilities. ### Orthotic Repairs 1. Total cost of all repairs per device per two year period not to exceed 50% of the cost of a replacement orthotic device. 2. Total cost of repair to a component is not to exceed 50% of the AADL maximum contribution for that component. 3. Repairs over $800 contact AADL for prior approval 4. If a new device is prescribed within 3 months of a major repair ($800.00), 50% of the cost of the repair will be deducted from the initial procedure on the cost of the new device. 5. Repairs or maintenance to knee orthosis must be authorized and invoiced under O616. 6. Shipping and Brokerage Fees where a device or component is: under warranty and is being replaced/repaired by the manufacturer, there should be no cost for "materials", and no "shipping or brokerage fees". under warranty and being replaced, it must be provided under the appropriate AADL catalogue number (shipping and brokerage fees are already included). is not under warranty and being repaired by the manufacturer, shipping and brokerage fees may be included under O615. Flat Rate Maintenance of Knee Orthosis 1 Maintenance of Knee Orthosis Per 2 Years O616 $354.00 Each O514 $177.00 Each O615 $300.00 Max. Each Up to $354 every 2 years. Upgrade. Labour 10 Repairs Per 12 Months Hours - $177.00/hr. Indicate on invoice # of hrs. & total $ of hrs. only. Documentation required: - Describe repair/mod - # of hrs. and cost - Total cost of repair (hrs.+ materials) - % of total repair cost of device/component Materials 4 Repair Materials Per 12 Months Invoice quantity = 1 per repair/modification. Quantity of 1 is up to a maximum price of $300. Documentation required: List of materials and cost. © 2013 Government of © 2014 Government of Alberta Alberta April April 1, 1, 2014 2014 Page APL O-25 26 of 26
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