MEDICARE'S THERAPEUTIC SHOE BILL
According to the American Diabetes Association, there are approximately 16 million Americans with diabetes. Unfortunately, this number continues to grow. Twenty-five percent of persons with diabetes develop foot problems related to the disease. Recognizing this problem, Congress approved the Medicare Therapeutic Shoe Bill, helping thousands of persons with diabetes obtain protective footwear and inserts.
Medicare Beneficiary Eligibility
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; and
(b) The certifying physician who is managing the patients systemic diabetes condition has certified that (1) one or more of the indications required by (a) above are present, (2) he or she is treating the patient under a comprehensive plan of care for his or her diabetes, and (3) the patient needs diabetic shoes, inserts or modifications.
What is Covered?
For Medicare beneficiaries meeting criteria described above, coverage is limited to one of the following within 1 calendar year:
- 1 pair of off-the-shelf depth shoes and 3 additional pairs of multi-density inserts.
- 1 pair of off-the-shelf depth shoes including a modification, and 2 additional pairs of multi-density inserts.
- 1 pair of custom-molded shoes and 2 additional pair of multi-density inserts.
Medicare program carriers generally require the following before reimbursement will be made for shoes, inserts or modifications furnished to a program beneficiary.
- A certification of medical necessity from the physician who manages the patients diabetes, which certifies that the patient (a) has diabetes mellitus, (b) has at least one of the qualifying conditions, (c) is being treated under a comprehensive plan of care for his or her diabetes, and (d) needs diabetic shoes. Medicare carriers recommend that suppliers use the Medicare approved Statement of Certifying Physician for Therapeutic Shoes form to fulfill this requirement.
- 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. Suppliers are required to keep file copies of signed and dated physician prescriptions.
Furnishing The Footwear
The footwear must be fitted and furnished by a podiatrist or other qualified individual, such as a pedorthist, orthotist, or prosthetist. The certifying physician may not furnish the footwear unless he or she practices in a defined rural area or health professional shortage area. The prescribing physician may be the supplier.
Additional requirements may apply. You should consult a qualified expert or Medicare for more information.
The information contained herein is a summary of select Medicare rules and policies, and is intended for information purposes only. For comprehensive or authoritative guidance, please consult Medicare program representatives and publications.