An Explanation of Benefits
The Centers for Disease Control and Prevention (CDC) estimates that 23.1-million Americans have been diagnosed with diabetes. Studies have shown that 25 percent of persons with diabetes develop foot problems related to the disease and that up to 15 percent 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.
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.
