Therapeutic footwear plays a significant role in preventing severe foot complications for individuals managing diabetes. Specialized shoes and inserts are designed to reduce pressure points, decrease friction, and accommodate foot deformities. Recognizing this preventative measure as part of comprehensive diabetes management, Medicare does cover therapeutic footwear under specific, clearly defined conditions. This medical coverage is an allowance for diabetic foot care, and understanding the requirements and the process is necessary for beneficiaries to access this important benefit.
Medicare Coverage and Cost Structure
Medicare provides coverage for therapeutic shoes and custom inserts through Part B, classifying them as Prosthetic Devices. This coverage is distinct from Medicare Part A and Part D. Therapeutic footwear is covered only when a beneficiary has diabetes and meets specific criteria indicating a high risk for foot complications.
Once the Part B annual deductible is satisfied, Medicare typically covers 80% of the approved amount for the shoes and inserts. The beneficiary is responsible for the remaining 20% coinsurance cost. Beneficiaries must ensure they use a Medicare-enrolled supplier who accepts “assignment,” which means the supplier agrees to accept the Medicare-approved amount as the total payment. If a supplier does not accept assignment, they may charge the beneficiary more than the 20% coinsurance, leading to higher out-of-pocket expenses.
Qualifying for Diabetic Footwear Coverage
To be eligible for this coverage, an individual must have diabetes and meet a specific medical necessity criterion related to their feet. The certifying physician, who must be a Doctor of Medicine (MD) or Doctor of Osteopathy (DO), must document that the patient is under a comprehensive plan of care for their diabetes. This physician must also certify that the patient has one or more qualifying conditions that demonstrate the medical need for therapeutic footwear.
Qualifying conditions include:
- A history of partial or complete foot amputation.
- A history of foot ulceration.
- Evidence of pre-ulcerative callus formation, which signals a high-pressure area.
- Peripheral neuropathy coupled with evidence of callus formation.
- Significant foot deformity.
- Poor circulation in the feet.
The certifying physician’s documentation must clearly link the patient’s diabetes to the specific foot condition requiring specialized footwear. This step ensures that the therapeutic shoes are considered medically necessary for preventing severe complications, rather than being simply comfort or standard footwear. This certification process must be completed annually to maintain eligibility for replacement items.
Specific Items and Annual Replacement Limits
The annual allowance includes one pair of therapeutic shoes per calendar year, which can be either extra-depth shoes or custom-molded shoes. Extra-depth shoes are the most common option and are designed to accommodate special inserts and minor foot deformities.
Custom-molded shoes are covered if the patient has a severe foot deformity that cannot be accommodated by extra-depth footwear. Medicare covers the accompanying inserts, but the quantity depends on the type of shoe received. For extra-depth shoes, three pairs of custom-molded or depth inserts are covered each calendar year.
If a beneficiary receives custom-molded shoes, the coverage includes the inserts that come with the shoes plus two additional pairs of inserts, totaling three pairs annually. Shoe modifications may also be covered as a substitute for a pair of inserts if medically appropriate.
Steps to Obtain Covered Footwear
The process for obtaining Medicare-covered therapeutic footwear begins with the physician managing the patient’s diabetes. The physician must confirm that the patient has diabetes and meets one of the qualifying foot conditions. The physician must sign a statement certifying the medical necessity for the shoes and inserts.
Following the certification, a qualified prescribing practitioner, such as a podiatrist or other doctor, must write a detailed prescription for the specific therapeutic shoes and inserts. The prescription must clearly specify the type of footwear needed to address the patient’s documented foot condition. The patient must then take this documentation to a qualified supplier.
The shoes must be purchased from a supplier who is enrolled in Medicare and accepts assignment. Medicare will not pay claims submitted by a supplier who is not enrolled, leaving the beneficiary responsible for the full cost. The supplier, who can be a pedorthist, orthotist, or podiatrist, is responsible for correctly fitting the shoes and submitting the claim to Medicare.