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
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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 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
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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 - 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
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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 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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