Orthotic shoe inserts are specialized devices designed to support and align the foot, ankle, and leg. Unlike generic arch supports, these medical devices are intended for therapeutic purposes. Coverage is highly conditional, limited almost exclusively to instances where the inserts are medically necessary to prevent severe complications, typically for individuals with diabetic foot disease. This coverage falls under the Durable Medical Equipment (DME) benefit, but with very strict rules.
Coverage Rules Under Medicare Part B
Medicare Part B covers outpatient medical services and Durable Medical Equipment, providing limited coverage for orthotic shoe inserts. This coverage is specifically for “therapeutic shoes” and inserts used to prevent serious foot complications in people with diabetes, not for general foot pain or comfort orthotics.
To receive coverage, the inserts must be integral to a pair of therapeutic shoes (extra-depth or custom-molded) coded under the Healthcare Common Procedure Coding System (HCPCS) A5500 series. If qualifying criteria are met, Medicare Part B covers 80% of the Medicare-approved amount after the annual deductible is satisfied. The beneficiary is responsible for the remaining 20% coinsurance.
The physician managing the patient’s diabetes must certify the need for the therapeutic shoes and inserts under a comprehensive care plan. Without this physician certification, coverage is denied. Medicare views this footwear as a targeted intervention to avoid severe outcomes like ulcers and amputation. General orthotics not associated with severe diabetic foot disease remain uncovered.
Specific Medical Necessity Requirements
To qualify for coverage, a patient must have diabetes and demonstrate severe diabetic foot disease, certified by the treating physician. The clinical criteria are precise, focusing on conditions where improper footwear poses a clear and immediate threat to the patient’s foot health.
Qualifying Conditions
Qualifying conditions include:
- A history of partial or complete foot amputation.
- Previous foot ulceration or the presence of pre-ulcerative calluses.
- Peripheral neuropathy showing evidence of callus formation.
- A foot deformity requiring therapeutic accommodation.
The treating doctor must document the patient’s condition and certify that the patient is under a comprehensive plan of care for their diabetes. This certification works in conjunction with a qualified prescriber, such as a podiatrist, who orders the specific footwear type.
Coverage is limited to a specific quantity per calendar year. A patient can receive one pair of therapeutic shoes (custom-molded or extra-depth) per year. For inserts, the limit is three pairs of custom-molded inserts or six pairs of non-custom inserts annually, depending on the shoe type selected.
Navigating the Documentation and Supplier Process
Securing Medicare coverage for therapeutic shoes and inserts requires meticulous documentation to support the medical necessity. The process begins with the physician managing the patient’s diabetes providing a detailed certification of need. This certification must include documentation from a recent physical examination that supports the qualifying condition, such as evidence of neuropathy or a foot deformity.
A separate, written order or prescription for the specific type of shoe and inserts must then be issued by a qualified prescriber, such as a podiatrist. This order must contain all necessary details and be provided to the supplier before the items are dispensed. The patient must obtain the therapeutic footwear from a supplier enrolled in the Durable Medical Equipment Prosthetics Orthotics and Supplies (DMEPOS) program.
It is important that the supplier accepts Medicare assignment, meaning they agree to accept the Medicare-approved amount as full payment. If a supplier does not accept assignment, the patient may be billed for the difference between the supplier’s charge and the approved amount. If there is any question about coverage, the supplier should provide an Advance Beneficiary Notice of Non-coverage (ABN), which informs the patient they may be financially responsible if Medicare denies the claim.
Coverage Through Medicare Advantage Plans
Medicare Advantage (Part C) plans are offered by private insurance companies and must cover all services that Original Medicare (Parts A and B) covers. This means Part C plans must cover therapeutic shoes and inserts for qualifying diabetic patients who meet the strict Part B criteria.
Part C plans often provide additional benefits that Original Medicare does not, which may extend to foot-related devices. Some plans may offer coverage for general, non-diabetic orthotics or pedorthic services outside the limited scope of the Part B benefit. The cost structure, such as copayments or coinsurance, may also differ from the standard 20% coinsurance under Part B.
Patients enrolled in a Medicare Advantage plan should consult their Evidence of Coverage (EOC) document to understand the specifics of their benefits. The plan may require the use of in-network suppliers or have different prior authorization procedures than Original Medicare. Verification with the plan is necessary to confirm any additional coverage for orthotics and to ensure the supplier is within the plan’s network.