Medicare Information

Medicare Coverage of Therapeutic Footware for People with Diabetes

Medicare provides coverage for depth-inlay shoes, custom-molded shoes, and shoe inserts for people with diabetes who qualify under Medicare Part B. Designed to pre vent lower-limb ulcers and amputations in people who have diabetes, this Medicare benefit can pre vent suffering and save money.
 

How Individuals Qualify

The M.D. or D.O. treating the patient for diabetes must certify that the individual:

1. Has diabetes.

2. Has one or more of the following conditions in one or both feet:

   • history of partial or complete foot amputation

   • history of previous foot ulceration

   • history of pre-ulcerative callus

   • peripheral neuropathy with evidence of callus formation

   • poor circulation

   • foot deformity

3. Is being treated under a comprehensive diabetes care plan and needs therapeutic shoes and/or inserts because of diabetes.
    

Type of Footwear Covered

If an individual qualifies, he/she is limited to one of the following footwear categories within each calendar year:

1. One pair of depth shoes and three pairs of inserts

2. One pair of custom-molded shoes (including inserts) and two additional pairs of inserts.

Separate inserts may be covered under certain criteria. Shoe modification is covered as a substitute for an insert, and a custom-molded shoe is covered when the individual has a foot deformity that cannot be accommodated by a depth shoe.
 

What the Physician Needs to Do

1. The certifying physician (the M.D. or D.O.) over seeing the diabetes treatment must review and sign a “Statement of Certifying Physician for Therapeutic Shoes” (see form).

2. The prescribing physician (the D.P.M., D.O., or M.D.) must complete a footwear prescription (see form). Once the patient has the signed statement and the prescription, he/she can see a podiatrist, orthotist, prosthetist or pedorthist to have the prescription filled. The supplier will then submit the Medicare claim form (Form HCFA 1500) to the appropriate Durable Medical Equipment Regional Carrier (DMERC), keeping copies of the claim form and the original statement and prescription.

Note that in most cases, the certifying physician and the prescribing physician will be two different individuals.
 

Patient Responsibility for Payment

Medicare will pay for 80% of the payment amount allowed. The patient is responsible for a minimum of 20% of the total payment amount and possibly more if the dispenser does not accept Medicare assignment and the dispenser’s usual fee is higher than the payment amount. The maximum payment amounts per pair as of 2000 are:

ICD-9 codes

Because this benefit is available only to people with diabetes, an appropriate ICD-9 code (250.00-250.93) is required when completing the Statement of Certifying Physician.

National Diabetes Education Program (NDEP)    http://ndep.nih.gov
NIDDK, National Institutes of Health, Bethesda, MD

A Joint Initiative of the National Institutes of Health and the
Centers for Disease Control and Prevention