Therapeutic shoes for diabetics are not DME and are not considered DME nor orthotics, but a separate category of coverage under Medicare Part B. Diabetic shoes are covered if the requirements as specified in this section concerning certification and prescription are fulfilled.
In addition, this benefit provides for a pair of diabetic shoes even if only one foot suffers from diabetic foot disease. Each shoe is equally equipped so that the affected limb, as well as the remaining limb, is protected. Claims for therapeutic shoes for diabetics are processed by the Durable Medical Equipment Medicare Administrative Contractors (DME MACs).
Coverage
For each individual, coverage of the footwear and inserts is limited to one of the following within one calendar year:
- No more than one pair of custom-molded shoes (including inserts provided with such shoes) and two additional pairs of inserts; or
- No more than one pair of depth shoes and three pairs of inserts (not including the non-customized removable inserts provided with such shoes).
Orthopedic shoes, as stated in the Medicare Claims Processing Manual, are not covered. This exclusion does not apply to orthopedic shoes that are an integral part of a leg brace. In situations in which an individual qualifies for both diabetic shoes and a leg brace, these items are covered separately. The following items may be covered under the diabetic shoe benefit:
1. Custom-molded shoes are shoes that:
- Are constructed over a positive model of the patient’s foot;
- Are made from leather or other suitable material of equal quality;
- Have removable inserts that can be altered or replaced as the patient’s condition warrants;
- Have some form of shoe closure.
2. Depth Shoes Depth shoes are shoes that:
- Have a full length, a heel-to-toe filler that, when removed, provides a minimum of 3/16 inch of additional depth used to accommodate custom-molded or customized inserts;
- Are made from leather or other suitable material of equal quality;
- Have some form of shoe closure; and
- Are available in full and half sizes with a minimum of three widths so that the sole is graded to the size and width of the upper portions of the shoes according to the American standard last sizing schedule or its equivalent. (The American standard last sizing schedule is the numerical shoe sizing system used for shoes sold in the United States.)
3. Inserts are total contact, multiple densities, removable inlays that are directly molded to the patient’s foot or a model of the patient’s foot or directly carved from a patient-specific, rectified electronic model and that are made of a suitable material with regard to the patient’s condition.
Substitution of Modifications for Inserts
An individual may substitute modification(s) of custom-molded or depth shoes instead of obtaining a pair(s) of inserts in any combination. Payment for the modification(s) may not exceed the limit set for the inserts for which the individual is entitled. The following is a list of the most common shoe modifications available:
- Rigid Rocker Bottoms
- Roller Bottoms (Sole or Bar)
- Metatarsal Bars
- Wedges (Posting)
- Offset Heels
Inserts may be covered and dispensed independently of diabetic shoes if the supplier of the shoes verifies in writing that the patient has appropriate footwear into which the insert can be placed. This footwear must meet the definitions for depth shoes and custom-molded shoes.
Certification
The need for diabetic shoes must be certified by a physician who is a doctor of medicine or a doctor of osteopathy and who is responsible for diagnosing and treating the patient’s diabetic systemic condition through a comprehensive plan of care.
Prescription
Following certification by the physician managing the patient’s systemic diabetic condition, a podiatrist or other qualified physician who is knowledgeable in the fitting of diabetic shoes and inserts may prescribe the particular type of footwear necessary.
Furnishing Footwear
The footwear must be fitted and furnished by a podiatrist or other qualified individuals such as a pedorthist, an orthopedist, or a prosthetist. The certifying physician may not furnish the diabetic shoes unless the certifying physician is the only qualified individual in the area.
Reference:
New “K” Code for Therapeutic Shoe Inserts
FAQs
1. Are therapeutic shoes for diabetics covered by insurance?
Yes, Medicare and many private insurers cover them if eligibility criteria are met. Documentation from a physician is required.
2. What documentation is needed to bill for diabetic shoes?
You need a detailed prescription and a statement of medical necessity from the treating physician. Proper records ensure claim approval.
3. How often can diabetic patients get therapeutic shoes?
Medicare typically covers one pair of shoes and three inserts per calendar year. Reimbursement rules must be followed.
4. Who can prescribe and fit therapeutic shoes?
A qualified physician must prescribe them, and a certified specialist must fit the shoes. This ensures compliance and proper care.
5. What are common billing issues with diabetic shoe claims?
Missing documentation, incorrect codes, or lack of proper provider credentials can cause denials. Attention to detail is essential.
