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June 03, 2011

Shoes and Foot Inserts - Coverage Reminder

Recently questions have been asked about coverage of shoes and inserts for Medicare beneficiaries. Medicare coverage of shoes and inserts is limited by benefit categories established in the Social Security Act. The information below summarizes the key statutory and benefit requirements related to shoes and inserts.

Therapeutic Shoes and Inserts for Persons with Diabetes

Social Security Act ��1861(s)(12) and 1833(o) provides for coverage of therapeutic shoes and inserts for persons with diabetes mellitus. This is a separate Medicare benefit distinct from the durable medical equipment (DME) or orthotics benefits. Under the Therapeutic Shoes benefit, beneficiaries are entitled to one (1) pair of shoes and three (3) sets of inserts each calendar year. In order to qualify for coverage under this benefit, the beneficiary must have a diagnosis of diabetes. Therapeutic shoes and inserts for beneficiaries with conditions other than diabetes mellitus are non-covered (no benefit) with the exception noted below.

Claims for therapeutic shoes and inserts for persons with diabetes utilize specific Healthcare Common Procedure Coding System (HCPCS) codes. Those codes are:

As noted in the code descriptors above, these codes are used to bill claims only for beneficiaries with diabetes and who meet the qualifying coverage criteria outlined in the Social Security Act, Medicare Benefit Policy Manual (Internet-only Pub. 100-2, Chapter 15, Section 140) and the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) local coverage determination (LCD) and related policy article entitled Therapeutic Shoes for Persons with Diabetes.

Orthopedic Shoes and Modification

Orthopedic shoes are excluded from coverage by the Social Security Act, �1862(a)(8). In addition, the Act specifically excludes treatment and devices for flat feet, subluxations of the foot and routine foot care (see SSA �1862(a)(13)). The only exceptions to these benefit category provisions are:

  1. Use of an orthopedic shoe(s) attached to a brace in which case coverage is governed by the brace/orthotic benefit in the Act �1861(s)(9) with additional guidance in the Medicare Benefit Policy Manual (Internet-only Pub. 100-2, Chapter 15, Section 130), the Medicare Claims Processing Manual (Internet-only Pub. 100-4, Chapter 20, various sections) and the DME MAC LCD and related policy article entitled Orthopedic Footwear.
  2. For persons with diabetes only, substitution of modification(s) of custom-molded or depth shoes instead of obtaining a pair(s) of inserts in any combination. Payment for the modification(s) may not exceed the limit set for the inserts for which the individual is entitled.

In other words, orthopedic shoes, inserts and modifications billed using the HCPCS codes below may only be billed when attached to a brace, in which case the shoes, inserts and/or modifications must be billed by the supplier billing the brace or as a substitute for inserts in beneficiaries entitled to therapeutic shoes and inserts by virtue of a diabetes diagnosis.

The HCPCS codes billed for orthopedic shoes, inserts and modifications as described above are:

This article is a summary of selected coverage, coding and documentation requirements for shoes, inserts and modifications. Suppliers are strongly encouraged to familiarize themselves with the applicable Medicare statutory requirements and exclusions, benefit language and local coverage policies for these items. LCD and Policy Article are on the CMS Web site at http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx.