Does Medicare Cover Foot Orthotics?

Medicare Part B covers certain foot orthotics when medically necessary. These devices are generally categorized under Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). However, specific foot orthotics, like therapeutic shoes and inserts for individuals with diabetes, fall under a distinct benefit. Coverage is not universal and depends on specific medical conditions and Medicare’s established requirements.

Types of Foot Orthotics Medicare Covers

Medicare Part B covers specific categories of foot orthotics, focusing on therapeutic benefits rather than comfort. Over-the-counter shoe inserts or general comfort orthotics are typically not covered. Covered items often include custom-molded orthotics and certain therapeutic shoe inserts.

Custom-molded orthotics are devices fabricated from a direct mold or impression of a patient’s foot, ensuring a precise and individualized fit. These differ significantly from prefabricated or off-the-shelf inserts, which are mass-produced. Medicare generally covers custom-molded orthotics when prescribed for specific medical conditions.

For individuals with diabetes, Medicare covers therapeutic shoes and inserts to prevent complications. This includes one pair of custom-molded shoes and inserts, or one pair of extra-depth shoes with three pairs of inserts, per calendar year. Shoe modifications can also be covered as an alternative to inserts.

Medical Conditions for Coverage

Coverage for foot orthotics under Medicare is strictly contingent upon documented medical necessity. This means the orthotics must be required for the treatment of a specific illness, injury, or to improve the function of a malformed body part. The primary conditions that often qualify for coverage relate to severe diabetic foot disease.

For custom-molded orthotics or therapeutic shoe inserts, Medicare requires a diagnosis of diabetes with specific severe foot complications. These complications may include a history of foot ulceration, partial or complete foot amputation, or peripheral neuropathy with evidence of callus formation. Other qualifying conditions can involve poor circulation or foot deformities that cannot be accommodated by standard footwear.

Physician documentation must clearly outline the specific medical condition and how the prescribed orthotic device will address it, preserving or enhancing the patient’s condition. Beyond diabetic foot conditions, Medicare Part B also covers other medically necessary orthoses, such as Ankle-Foot Orthoses (AFOs) and Knee-Ankle-Foot Orthoses (KAFOs). These are covered for conditions like stroke, multiple sclerosis, or cerebral palsy that lead to mobility impairments.

Steps to Secure Medicare Coverage

Securing Medicare coverage for foot orthotics begins with thorough documentation of medical necessity. The initial step requires obtaining a detailed prescription from a qualified physician, such as a Doctor of Medicine (MD), Doctor of Osteopathy (DO), or Doctor of Podiatric Medicine (DPM), who is enrolled in Medicare. This prescription must clearly outline the specific orthotic device, its intended purpose, and the medical justification for its use, including relevant diagnosis codes.

The physician’s medical records must contain comprehensive information supporting the diagnosis and functional limitations, demonstrating how the orthotic device is reasonable and necessary for treatment. This documentation is crucial for the supplier to submit a valid claim to Medicare. After documentation and prescription are in hand, the next phase involves obtaining the orthotics.

Beneficiaries must select a Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) supplier who is enrolled in Medicare and accepts assignment. This ensures that the supplier agrees to Medicare’s approved payment amount. The chosen supplier will then verify coverage, obtain any required prior authorizations, and submit the claim to Medicare on the beneficiary’s behalf. The supplier is also responsible for proper fitting and delivery of the orthotics, along with instructing the beneficiary on their use. If a claim is denied, understanding the specific reason for denial from Medicare or the supplier is the first step, and beneficiaries can explore the Medicare appeal process.

Understanding Your Out-of-Pocket Costs

When Medicare Part B covers foot orthotics, beneficiaries are responsible for a portion of the costs. After meeting the annual Part B deductible, which is $257 in 2025, Medicare pays 80% of the Medicare-approved amount for the orthotic device. The beneficiary is responsible for the remaining 20% coinsurance.

For example, if a covered orthotic has a Medicare-approved cost of $500 and the deductible has been met, Medicare pays $400, leaving the beneficiary responsible for $100. Supplemental insurance plans, such as Medigap, may help cover these out-of-pocket costs, including the 20% coinsurance and the Part B deductible. Medicare Advantage plans also cover orthotics, but their cost-sharing structures, including premiums, deductibles, and coinsurance, can vary significantly by plan. Discuss estimated costs with the DMEPOS supplier before obtaining the orthotics to understand the full financial responsibility.