Medicare Coverage of Therapeutic Footwear for People with Diabetes
Medicare provides coverage for depth-inlay shoes, custom-molded shoes, and
shoe inserts for people with diabetes who qualify under Medicare Part B.
Designed to prevent lower-limb ulcers and amputations in people who have
diabetes, this Medicare benefit can prevent suffering and save money.
How Individuals Qualify
The M.D. or D.O. treating the patient for
diabetes must certify that the individual:
1. Has diabetes.
2. Has one or more of the following
conditions in one or both feet:
- history of partial or complete foot amputation
- history of previous foot ulceration
- history of preulcerative callus
- peripheral neuropathy with evidence of callus
- poor circulation
- foot deformity
3. Is being treated under a
comprehensive diabetes care plan and needs therapeutic shoes and/or inserts
because of diabetes.
Type of Footwear Covered
If an individual qualifies, he/she is limited to one of the
following footwear categories within one calendar year:
1. One pair of depth-inlay shoes and three pairs of
2. One pair of custom-molded shoes (including
inserts) and two additional pairs of inserts.
Separate inserts may be covered under certain criteria. Shoe
modification is covered as a substitute for an insert, and a custom-molded shoe
is covered when the individual has a foot deformity that cannot be accommodated
by a depth shoe.
What the Physician Needs to Do
1. The certifying
physician (the M.D. or D.O.) overseeing the diabetes treatment must review
and sign a "Certification Statement for Therapeutic Footwear".
2. The prescribing physician (the D.P.M.,
orthopedic foot surgeon, or M.D.) must complete a "Prescription Form for
Therapeutic Footwear". Once the patient has the signed statement and the
prescription, he/she can see a podiatrist, orthotist, prosthetist, or
pedorthist to have the prescription filled. The supplier will then submit the
Medicare claim form (Form HCFA 1500) to the appropriate Durable Medical
Equipment Regional Carrier (DMERC), keeping copies of the claim form and the
original statement and prescription.
Note that in most cases the certifying physician and the
prescribing physician will be two different individuals.
Patient Responsibility for Payment
Medicare will pay for 80% of the payment amount allowed
either directly to the patient or by reimbursement. The patient is responsible
for a minimum of 20% of the total payment amount and possibly more if the
dispenser does not accept Medicare assignment and if the dispenser's usual fee
is higher than the payment amount. The maximum payment amount per pair as of
1997 is listed below. These figures may change.
Total Amount Allowed
Amount Covered by Medicare
Inserts or modifications
Because this benefit is available only to people with diabetes, an
appropriate ICD-9 code (250.00-250.91) is required when completing the
Statement of Certifying Physician.
The Pedorthic Dispenser
Properly fitting therapeutic footwear requires special
skills and care. The pedorthic profession focuses on the design, fit, and
modification of shoes and related foot appliances. For a listing of
pedorthists, send a self-addressed stamped envelope to the Board for
Certification in Pedorthics, 9861 Broken Land Pkwy, #255, Columbia, MD