Therapeutic footwear is a preventative measure for individuals with diabetes. Diabetes often causes nerve damage (peripheral neuropathy), reducing sensation in the feet and allowing minor injuries to go unnoticed. Specialized shoes prevent skin breakdown, ulcers, and severe infections that can lead to amputation. Understanding Medicare coverage for this equipment is a primary concern for beneficiaries managing their diabetes.
The Core Answer: Medicare Coverage Status
Medicare does cover therapeutic diabetic footwear for qualifying beneficiaries as part of the Durable Medical Equipment (DME) benefit. This coverage is specifically provided under Medicare Part B, which is the component responsible for medical insurance. The inclusion of this benefit recognizes that proper footwear is a necessary medical intervention rather than a comfort item.
Therapeutic shoes are viewed as a prosthetic device benefit when deemed medically necessary to protect the feet of individuals with severe diabetic foot disease. This coverage ensures that beneficiaries have access to appropriate protection to maintain their mobility and overall health.
Essential Eligibility Requirements
To qualify for coverage, a patient must have a diabetes diagnosis and be under the care of a physician actively managing their condition. Meeting these initial criteria is only the first step, as Medicare requires evidence of a severe diabetes-related foot condition to establish medical necessity. Regulations specify six qualifying conditions that must be present in one or both feet for coverage approval.
Qualifying Foot Conditions
The qualifying conditions include:
- A history of a previous foot ulceration.
- A prior amputation of the foot or part of the foot.
- The presence of pre-ulcerative callus formation.
- Peripheral neuropathy accompanied by callus formation.
- A significant foot deformity.
- Poor circulation in the feet.
What the Coverage Includes and Annual Limits
Medicare limits coverage to one pair of therapeutic shoes per calendar year. The type of footwear covered can be either extra-depth shoes or custom-molded shoes, depending on the severity of the patient’s foot condition. Custom-molded shoes are generally reserved for individuals with severe foot deformities that extra-depth footwear cannot accommodate.
Medicare also covers specialized inserts, which help to redistribute pressure and reduce friction inside the shoe.
Annual Insert Limits
- For extra-depth shoes, the limit is three pairs of inserts per calendar year.
- For custom-molded shoes, coverage includes the inserts that come with the shoes, plus two additional pairs annually.
- Shoe modifications can be covered as a substitute for one pair of inserts.
The Process: Obtaining Covered Diabetic Shoes
The process begins with the physician managing the patient’s diabetes (the certifying physician). This physician must complete a certification form confirming the patient has diabetes, is under a comprehensive care plan, and meets at least one qualifying foot condition. This certification is a foundational document for the claim.
Next, a qualified prescribing physician, such as a podiatrist or orthopedist, must perform a detailed foot examination and write a prescription. The prescription specifies the required type of shoes and inserts based on the patient’s specific foot assessment.
The patient must take this documentation to a Medicare-enrolled supplier who agrees to accept assignment. The supplier is responsible for fitting the shoes and submitting the claim. It is paramount that the supplier accepts assignment, meaning they agree to accept the Medicare-approved amount as full payment.
Costs to the Patient (Deductibles and Coinsurance)
Coverage for therapeutic shoes falls under Medicare Part B, which means the patient is responsible for certain out-of-pocket costs. Before Medicare begins to pay its share, the patient must first satisfy the annual Part B deductible.
Once the deductible has been met, Medicare pays 80% of the Medicare-approved amount for the therapeutic shoes and inserts. The patient is then responsible for the remaining 20% coinsurance of the approved amount. Patients with supplemental insurance, such as Medigap or a Medicare Advantage plan, may have their coinsurance or deductible costs covered, depending on the specific policy details.