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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
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| 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.
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| 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.
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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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Right 2001
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