TRICARE Manuals - Display Chap 8 Sect 8.2 (Change 94, Jan 5, 2022)

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Chapter 8

Section 8.2

Therapeutic Shoes For Diabetics

Issue Date: February 27, 1996

Authority: 32 CFR 199.2 and 32 CFR 199.4

Revision: C-46, April 30, 2019

1.0 HCPCS PROCEDURE CODES

A5500 - A5514

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-A5514 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 Exclusion

Shoes for conditions other than diabetes.

6.0 EFFECTIVE DATE

May 1, 1993.

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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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