Diabetic Shoes/Inserts

Coverage Criteria:

  • Coverage critera must meet 1, 2 and 3 below:
    1. Patient has diabetes mellitus (249.00 - 250.93)
    2. Certifying Physician documents one or more of the following conditions in the patient's medical record (of Primary Care Physician) and certifies these conditions on the certifying statement:
      • 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
    3. Certifying Physician must either:
      • Personally document one or more of the above conditions in the medical record by in-person visit within 6 months prior to delivery of the shoes and prior to or same day as signing the Certification Statement; or
      • Obtain, initial/sign, date and indicate agreement with information from the medical records of all in-person visit with a Podiatrist, other M.D., D.O, P.A., N.P., or CNS that is within 6 months prior to delivery of shoes.
  • Certifying Physician must also certify:
    1. Coverage criteria are met;
    2. He/She is treating the patient under a comprehensive plan of care;
    3. The patient needs diabetic shoes;
    4. The in-person visit is within 6 months prior to delivery of shoes/inserts and Certification Statement within 3 months prior to delivery of the shoes.
  • Prior to selecting product, the supplier must:
    1. Conduct an in-person evaluation documenting:
      • Examination of feet, description of abnormalities, accommodations required;
      • Measurement of feet;
      • Methodology utilized for custom molded inserts (cast, foam, other).
  • At time of delivery
    1. Conduct and document all in-person visit with the patient:
      • Evaluations with patient wearing shoes;
      • Document shoes, inserts and modifications to fit properly.

Coverage Limitations:

  • Limited to one pair within one calendar year

Therapeutic Shoes

  • Product Description: Pre-fabricated Diabetic Shoe with Custom or Heat Moldable Inserts
  • Product Treats: Diabetes
  • Product Utilization: Patient is ambulatory and has one of the following:
    1. History of partial or complete amputation of the foot; 2. History of previous foot ulceration; 3. History of pre-ulcerative callus; 4. Peripheral neuropathy with evidence of callus formation; 5. Poor circulation.
    Custom Diabetic Inserts utilized when the following criteria are met: hammer toes, bunions, calluses, peripheral neuropathy, foot deformities
    Heat Moldable Inserts utilitized when Custom Inserts are not indicated
    Toe Filler utilized when amputation of toes 1-5, 1-2 or great toe
  • Manufacturer: Dr. Comfort, OrthoFeet or Pedors
  • Sizes: Refer to vendor for specific sizes, use measuring stick
  • Coding: A5500 - Pre-fabricated Diabetic Shoes. Billed as one pair
    A5512 - Heat Moldable Inserts - 3 pair
    A5513 - Custom Inserts - 3 pair
    L5000 - Toe Filler - billed as 1 unit
    ICD: 250.00 - 250.93 - Diabetes Mellitus
    895.0 - 895.1 - Amputation of Toes/Use with Toe Filler
  • Required Documentation: Signed CMN prior to ordering shoes/inserts along with Nursing/Therapy/Physician Notes stating above diagnosis/conditions. If ordering Custom Inserts, must include description of why Custom Inserts are required on CMN in description section.
  • Adjunct Products: Trans Metatarsal Amputation Socks, L8417 must have TMA ICD: 895.0 - 895.1