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An Explanation of Benefits and Proper Shoe Selection

Medicare’s Therapeutic Shoe Benefit

The Centers for Disease Control and Prevention (CDC) estimates that nearly 20.8-million Americans are afflicted with diabetes. Studies have shown that 25 percent of persons with diabetes develop foot problems related to the disease and that up to 15 Medicare's Therapeutic Shoe Bill Guidepercent of persons with diabetes develop foot ulcers.

Since 1993, Medicare has covered certain therapeutic shoes, inserts and modifications for persons with diabetes who meet specified
qualifying requirements.

*Medicare covers diabetic shoes, inserts and modifications for program
beneficiaries only if the following criteria are met:

(a) the patient has diabetes and one or more of the following conditions:
• Previous amputation of the other foot, or part of either foot, or
• History of previous foot ulceration of either foot, or
• History of pre-ulcerative calluses of either foot, or
• Peripheral neuropathy with evidence of callus formation of either foot, or
• Foot deformity of either foot, or
• Poor circulation in either foot

(b) The patient has a prescription for a particular type of footwear (e.g., shoes, inserts,
modifications) from a podiatrist or physician who is knowledgeable in the fitting of diabetic shoes and inserts.

(c) A “Statement of Certifying Physician for Therapeutic Shoes” from a physician who manages the patient’s diabetes, which certifies that the patient (a) has diabetes mellitus, (b) has at least one of the qualifying conditions (see above), (c) is being treated under a comprehensive plan of care for his or her diabetes, and (d) needs diabetic shoes.

*What is Covered?

Coverage Limitations

For Medicare beneficiaries meeting the criteria described above, coverage is limited to one of the following within 1 calendar year:
• 1 pair of off-the-shelf depth shoes and up to 3 additional pairs of multi-density inserts.
• 1 pair of off-the-shelf depth shoes including a modification, and up to 2 additional pairs of multi-density inserts.
• 1 pair of custom-molded shoes and up to 2 additional pair of multi-density inserts.

Medicare Beneficiary Eligibility

Which Codes do you Reference? - A5500
For diabetics only, fitting, preparation and supply of off-the-shelf depth inlay shoe manufactured to accommodate multi-density inserts, per shoe. A depth shoe is one that 1) has a full length, heel-to-toe filler that when removed, provides a minimum of 3/16” of additional depth used to accommodate custom-molded or customized inserts, 2) is made from leather or other suitable material of equal quality. 3) has some form of shoe closure and 4) is available in full and half sizes with a minimum of three widths so that the sole is graded to the size and width of the upper portions of the shoe, according to the American standard last sizing schedule or its equivalent. (The American last sizing schedule is the numerical shoe sizing system used for shoes in the United States.) This includes a shoe with or without an internally seamless toe.

For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient’s foot,
including arch, base layer minimum of 1/4-inch material of shore (a 35 durometer) or 3/16-inch material of shore (a 40 durometer or higher), prefabricated, each.

For diabetics only, multiple density insert, custom molded from model of patient’s foot, total contact with patient’s foot, including arch, base layer minimum of 3/16-inch material
of shore (a 35 durometer or higher), includes arch filler and other shaping material, custom fabricated, each.

Note: Medicare instructs that when a pair of shoes, inserts or modifications is provided, two units of service should be reported on the claim; when a single unit is furnished, report only a single unit and code with appropriate modifers to indicate whether the unit was for the right or left foot.

Additional Requirements
Additional requirements may apply. You should consult a qualified expert or your
Medicare program representative for details.

* As noted by the PDAC

The information contained herein is a summary of Apex's understanding of select Medicare rules and policies, and is intended for information purposes only. Persons and entities participating in the Medicare program are responsible for understanding all applicable Medicare policies before submitting claims for payment to the program, and you should use this publication only as a guide. Failure to comply with such rules and requirements can have serious consequences. For comprehensive or authoritative guidance, please consult Medicare program representatives and publications or your counsel.