Other Services
Chapter 8
Section 8.2
Therapeutic
Shoes For Diabetics
Issue Date: February 27, 1996
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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