Medicare Shoe Benefit for People with Diabetes
Medicare provides coverage for depth-inlay shoes, custom-molded shoes, and shoe inserts for people with diabetes who qualify under Medicare Part B. Designed to prevent lower-limb ulcers and amputations in people who have diabetes, this Medicare benefit can prevent suffering and save money.
How Individuals Qualify
The M.D. or D.O. treating the patient for diabetes must certify that the individual:
1. Has diabetes.
2. Has one or more of the following conditions in one or both feet:
- history of partial or complete foot amputation
- history of previous foot ulceration
- history of pre-ulcerative callus
- peripheral neuropathy with evidence of callus formation
- poor circulation
- foot deformity
3. Is being treated under a comprehensive diabetes care plan and needs therapeutic shoes and/or inserts because of diabetes.
Type of Footwear Covered
If an individual qualifies, he/she is limited to one of the following footwear categories within one calendar year:
1. One pair of depth-inlay shoes and three pairs of inserts
2. One pair of custom-molded shoes (including inserts) and two additional pairs of inserts.
Separate inserts may be covered under certain criteria. Shoe modification is covered as a substitute for an insert, and a custom-molded shoe is covered when the individual has a foot deformity that cannot be accommodated by a depth shoe.
What the Physician Needs to Do
1. The certifying physician (the M.D. or D.O.) overseeing the diabetes treatment must review and sign a "Certification Statement for Therapeutic Footwear."
2. The prescribing physician (the D.P.M., orthopedic foot surgeon, or M.D.) must complete a "Prescription Form for Therapeutic Footwear." Once the patient has the signed statement and the prescription, he/she can see a podiatrist, orthotist, prosthetist, or pedorthist to have the prescription filled. The supplier will then submit the Medicare claim form (Form HCFA 1500) to the appropriate Durable Medical Equipment Regional Carrier (DMERC), keeping copies of the claim form and the original statement and prescription.
Note that in most cases the certifying physician and the prescribing physician will be two different individuals.
Patient Responsibility for Payment
Medicare will pay for 80% of the payment amount allowed either directly to the patient or by reimbursement. The patient is responsible for a minimum of 20% of the total payment amount and possibly more if the dispenser does not accept Medicare assignment and if the dispenser's usual fee is higher than the payment amount. The maximum payment amount per pair as of 1997 is listed below. These figures may change.
Total Amount Allowed
Amount Covered by Medicare
Inserts or modifications
Because this benefit is available only to people with diabetes, an appropriate ICD-9 code (250.00-250.91) is required when completing the Statement of Certifying Physician.
The Pedorthic Dispenser
Properly fitting therapeutic footwear requires special skills and care. The pedorthic profession focuses on the design, fit, and modification of shoes and related foot appliances. For a listing of pedorthists, send a self-addressed stamped envelope to:
Board for Certification in Pedorthics
9861 Broken Land Parkway
Excerpted and Adapted from the National Diabetes Education Program
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