Are Orthopedic Shoes Covered by Medicare?

Medicare, a federal health insurance program, helps millions of Americans access necessary medical care. This program helps cover a range of services, including certain medical supplies and durable medical equipment (DME). Among these provisions, orthopedic shoes are sometimes sought for various medical conditions. Understanding how Medicare approaches coverage for these specialized items requires a clear look at its specific guidelines and requirements.

Medicare Coverage Criteria

Medicare Part B provides coverage for therapeutic shoes and inserts under specific conditions, emphasizing the requirement for medical necessity. These items are covered primarily for individuals with diabetes who experience severe diabetes-related foot disease. Qualifying conditions often include a history of partial or complete foot amputation, previous foot ulceration, or pre-ulcerative calluses. Peripheral neuropathy with evidence of callus formation, foot deformity, or poor circulation in either foot also typically qualify for coverage.

The therapeutic shoes must be an integral part of a comprehensive treatment plan for these foot conditions, not merely for comfort or general support. A physician (M.D. or D.O.) must certify the medical necessity for these shoes. This certifying physician is responsible for managing the patient’s underlying diabetic systemic condition through a comprehensive plan of care.

The certifying physician must document in the patient’s medical record that they have diabetes and one or more of the qualifying foot conditions. The certifying physician must have an in-person visit with the beneficiary to address diabetes management within six months before the shoes are delivered. The certification statement must be signed on or after this visit and within three months prior to the delivery of the shoes or inserts.

Types of Covered Footwear

Medicare covers specific categories of therapeutic footwear and inserts once the medical necessity criteria are met. This includes extra-depth shoes and custom-molded shoes. Extra-depth shoes feature a full-length, heel-to-toe filler that, when removed, provides a minimum of 3/16 inch of additional depth to accommodate custom or customized inserts. Custom-molded shoes are built over a positive model of the patient’s foot, made from quality materials, and include removable inserts that can be altered or replaced as needed.

Medicare also covers various types of inserts designed for therapeutic purposes. These include custom-molded inserts, which are total contact, multiple-density, removable inlays directly molded to the patient’s foot or a model of it. Prefabricated inserts, which are heat-moldable and can be therapeutically appropriate, are also covered.

Beyond shoes and inserts, certain shoe modifications may also be covered when medically necessary as a substitute for an insert. Common modifications can include rigid rocker bottoms, wedges, or metatarsal bars. It is important to note that Medicare does not cover non-customized inserts or deluxe options, and inserts used in shoes not covered by Medicare are also not covered.

Obtaining Covered Footwear

Acquiring therapeutic shoes and inserts through Medicare involves several steps. The process begins with a physician’s order or prescription. A qualified physician, such as a podiatrist, endocrinologist, or other medical doctor, must prescribe the shoes. The physician managing the patient’s diabetes must confirm the need for therapeutic footwear as part of a comprehensive care plan.

Once the prescription and certification are in place, the footwear must be obtained from a Medicare-enrolled supplier. This can be a Durable Medical Equipment (DME) supplier, a podiatrist, an orthotist, a prosthetist, or a pedorthist. It is important to confirm that the chosen supplier is enrolled in Medicare and accepts assignment, meaning they agree to accept the Medicare-approved amount as full payment. If a supplier is not enrolled or does not accept assignment, Medicare will not pay the claims, and the patient may be responsible for the full cost.

A Standard Written Order (SWO) must be communicated to the supplier before the claim is submitted to Medicare. This order must include the patient’s name, a detailed description of the footwear, the quantity needed, the order date, and the physician’s signature and date. Medical records must clearly support the medical necessity for the shoes, detailing the patient’s condition and how the footwear will improve their mobility or functioning.

Understanding Costs and Limitations

Medicare Part B covers the cost of therapeutic shoes and inserts once the annual deductible is met. For 2025, the Medicare Part B annual deductible is $257. After meeting this deductible, Medicare Part B pays 80% of the Medicare-approved amount for these items. The patient is responsible for the remaining 20% coinsurance.

Medicare has specific frequency limits on the coverage of therapeutic footwear. Medicare covers one pair of therapeutic shoes per calendar year. For inserts, coverage includes three pairs per calendar year for extra-depth shoes and two pairs per calendar year for custom-molded shoes. These limits are strictly applied on a calendar year basis.

Coverage might be denied in several scenarios. Shoes or inserts purchased solely for comfort, general support, or for conditions that do not meet Medicare’s specific medical necessity criteria are not covered. Additionally, if the therapeutic shoes are not provided by a Medicare-enrolled supplier or if the prescribing physician’s documentation is incomplete or does not adequately support the medical necessity, coverage may be denied. It is important to adhere to all documentation and supplier requirements to ensure proper coverage.