Orthotics are external medical devices used to support, align, correct, or improve the function of movable parts of the body, such as the feet, ankles, and knees. These devices range from simple shoe inserts to complex leg or spinal braces designed to address musculoskeletal conditions. Medicare has specific definitions and requirements that must be met for coverage. This article clarifies how Medicare covers orthotics and foot braces, detailing the specific criteria and the patient’s financial responsibilities.
Coverage Under Medicare Part B
Orthotic devices are typically covered under Original Medicare Part B, which includes medical services and supplies classified under Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). Part B covers orthoses, defined as rigid or semi-rigid devices used to support a weakened body part or restrict movement in an injured area. For coverage to apply, the device must be medically necessary to treat an illness, injury, or specific physical condition.
The device must be prescribed by a treating physician, such as a Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO), or Doctor of Podiatric Medicine (DPM). The orthotic must also be supplied by a vendor or facility officially enrolled in and approved by Medicare.
Defining Medically Necessary Devices
A device qualifies as medically necessary when a physician confirms it is required for the treatment of a specific medical condition. For foot orthotics, Medicare provides coverage for therapeutic shoes and inserts specifically for individuals with diabetes and severe diabetes-related foot disease. This includes one pair of custom-molded shoes and inserts or one pair of extra-depth shoes annually, along with replacement inserts.
Coverage also extends to larger, complex braces that support the ankle, knee, or back, such as ankle-foot orthoses (AFOs) and knee-ankle-foot orthoses (KAFOs). These are covered because they are classified as external devices that mechanically support or correct a limb or joint.
Medicare generally does not cover routine foot care or common items like standard shoe inserts, over-the-counter arch supports, or comfort shoes. These items are typically not considered medically necessary orthoses.
The prescribing provider must furnish a Detailed Written Order (DWO) that confirms the patient’s specific diagnosis and the precise device required. This documentation is submitted to the supplier to justify the medical necessity of the item under Medicare’s guidelines. Without this documentation, the claim will likely be denied.
Patient Financial Responsibility
Under Original Medicare Part B, beneficiaries have specific out-of-pocket costs for covered orthotics and foot braces. The annual Part B deductible must be satisfied before Medicare begins payment. Once the deductible is met, the patient is responsible for a coinsurance payment.
The standard coinsurance amount is 20% of the Medicare-approved amount for the device. Medicare pays the remaining 80% directly to the enrolled supplier. Patients must confirm that the supplier accepts Medicare assignment, meaning they agree to accept the Medicare-approved amount as full payment.
Patients with a Medigap (Medicare Supplement Insurance) policy may have their supplemental plan cover the remaining 20% coinsurance after the Part B deductible is met. This coverage can significantly reduce out-of-pocket costs.
Coverage Through Medicare Advantage Plans
Medicare Advantage Plans must cover all medically necessary services that Original Medicare covers, including orthotics and foot braces. However, their cost structures and benefit administration differ significantly.
Part C plans often use fixed copayments instead of the 20% coinsurance model. These plans also operate with network restrictions, requiring the orthotic to be obtained from an in-network supplier. Furthermore, Medicare Advantage Plans frequently require prior authorization to confirm medical necessity and network compliance.