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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:
----- i) Previous amputation of the other foot, or part of either foot,
or
----- ii) History of previous foot ulceration of either foot, or
----- iii) History of pre-ulcerative calluses of either foot, or
----- iv) Peripheral neuropathy with evidence of callus formation of
either foot, or
----- v) Foot deformity of either foot, or
----- vi) Poor circulation in either foot; and
(B) The certifying physician who is managing the patient‘s 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.
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.
| Documentation Requirements |
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
patient's 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.
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.
Only then, the prescribing physician may be the supplier.
Additional requirements may apply. You should consult a qualified expert
or Medicare for more information.
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