Other Services
Chapter 8
Section 8.2
Therapeutic Shoes For Diabetics
Issue Date: February 27, 1996
Revision: C-1, March 10, 2017
1.0 HCPCS
PROCEDURE CODES
A5500 - A5513
2.0 DESCRIPTION
Therapeutic shoes (also referred to as extra
depth or diabetic shoes) including inserts and modifications are
designed for diabetics with conditions of impaired peripheral sensation
and/or altered peripheral circulation (e.g., diabetic neuropathy
and peripheral vascular disease), foot deformity, ulcerative
or pre-ulcerative callus formation,
or amputation. Therapeutic shoes, inserts
and modifications are not considered Durable Medical Equipment,
Orthotics, or Orthopedic Shoes (DMEPOS) because they serve a different
purpose for an individual with diabetes. The primary
goal of therapeutic shoes is to prevent complications, such as strain,
ulcers, calluses, or even amputations for patients with diabetes
and poor circulation. Therapeutic shoes and customized
insoles work together as a preventive system to help diabetics avoid
foot injuries and improve mobility. HCPCS codes A5500-A5513 indicate
the specific nature of the ordered items and are specific to those
with diabetes.
3.0 POLICY
3.1 Therapeutic
shoes, extra-depth shoes with inserts or custom molded shoes with
inserts and modifications, for individuals
with diabetes are covered, even if only one foot suffers
from diabetic foot disease.
3.2 Therapeutic shoes must be prescribed
by a physician and fit by a qualified individual, such as a certified
pedorthist.
3.3 The
shoe(s) must be equipped with a removable orthotic.
3.4 Separate shoes inserts shall be covered when
dispensed as a separate item for an otherwise covered therapeutic
shoe
for an individual with diabetes.
3.4.1 A podiatrist or other qualified
physician knowledgeable in the fitting of therapeutic shoes and
inserts prescribes the particular type of inserts necessary; and
3.4.2 The prescribing provider of the
shoes must verify in writing that the beneficiary has the medically
necessary footwear into which the inserts will be placed.
4.0 COVERAGE
LIMITATION
4.1 For each individual, coverage of the footwear
and inserts is limited to one of the following within one calendar
year:
4.1.1 One pair of custom molded shoes (including
inserts provided with such shoes) and two pairs of multidensity
inserts, or
4.1.2 One pair of extra-depth shoes (not including
inserts provided with such shoes) and three pairs of multidensity
inserts.
4.1.3 Modification of custom-molded or extra-depth
shoes may be substituted for one pair of inserts, other than the
initial pair of inserts. The most common modifications available
are:
• Rigid
rocker bottoms
• Roller
bottoms
• Metatarsal
bars
• Wedges
• Offset heels
4.2 The physician
who is managing the beneficiary’s systemic diabetic condition must:
4.2.1 Document
that the patient has diabetes.
4.2.2 Document that the patient
has one or more of the following conditions:
• Previous amputation
of the foot or part of the foot;
• History of previous
foot ulceration; or
• Pre-ulcerative callus
formation, or peripheral neuropathy with a history of callus formation,
foot deformity, or poor circulation.
4.2.3 Certify
that the patient is being treated under a comprehensive plan of
care for his diabetes and needs therapeutic shoes.
4.3 Related TRICARE Policies.
• For
orthotics, see Section 3.1.
• For
orthopedic shoes that are not an integral part of a brace (i.e.,
not attached) and other supportive foot devices, see Section 3.1, paragraph 4.1.
• Orthoses
for the Extended Care Health Option (ECHO) program, see Chapter 9, Sections 7.1, 15.1, and 17.1 and TED Edit 2-160-05R.
• Orthoses
for Active Duty Service Members (ADSMs) and the Supplemental Health
Care Program (SHCP), see TRICARE Operations Manual (TOM), Chapter 17, Section 3.
5.0
ExclusionShoes for conditions other than
diabetes.
6.0 EFFECTIVE
DATE
May 1, 1993.
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