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MEDICARE'S THERAPEUTIC
SHOE BILL
Introduction
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
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.
What is Covered?
Coverage Limitations
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.
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
Additional requirements may apply. You should consult a
qualified expert or Medicare for more information.
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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. |
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