Does Medicare Cover Orthotic Inserts?

Medicare, the federal health insurance program, helps millions of Americans manage their healthcare needs. Many individuals inquire about coverage for orthotic inserts, devices placed in shoes to support or correct foot issues. While Medicare does offer coverage for these items, it is not universal and comes with specific requirements. Understanding these details is important for beneficiaries.

Medicare Coverage Criteria for Orthotic Inserts

Medicare typically categorizes orthotic inserts as Durable Medical Equipment (DME), though therapeutic shoes and inserts for diabetics are covered under a separate benefit category within Part B. Coverage is primarily granted when orthotics are medically necessary to treat a specific medical condition. General foot pain, comfort issues, or preventative measures for non-covered conditions are generally not covered.

Coverage for orthotic inserts is often provided to individuals with severe diabetic foot disease, including a history of foot ulcers, partial or complete foot amputation, peripheral neuropathy with callus formation, or foot deformities like Charcot foot, hammertoes, or bunions. For these conditions, Medicare may cover one pair of custom-molded shoes with inserts or one pair of extra-depth shoes each calendar year. Beneficiaries may also receive two additional pairs of inserts for custom-molded shoes or three additional pairs for extra-depth shoes annually.

Other orthotics, such as Ankle-Foot Orthoses (AFOs) and Knee-Ankle-Foot Orthoses (KAFOs), are also covered when medically necessary. These devices must be rigid or semi-rigid and support a weakened body part or control movement in an injured or diseased area. Conditions like stroke, multiple sclerosis, or cerebral palsy often qualify for coverage of these braces. A physician’s diagnosis and prescription are always required, with detailed medical records supporting the necessity.

Steps to Obtain Medicare-Covered Orthotic Inserts

Obtaining Medicare-covered orthotic inserts begins with a consultation with a qualified physician, such as a podiatrist or endocrinologist, who confirms medical necessity. The physician’s documentation must clearly support the need, and for diabetes-related footwear, the doctor managing the diabetes must certify the necessity.

After receiving a prescription, find a Medicare-approved Durable Medical Equipment (DME) supplier. Verify the supplier is enrolled with Medicare and accepts Medicare assignment. You can use the Medicare.gov online directory or call 800-MEDICARE to find approved suppliers.

The approved supplier will handle fittings, measurements, and provide the orthotic inserts. They are typically responsible for filing the claim directly with Medicare. Beneficiaries should review their Explanation of Benefits (EOB) to understand covered services and amounts. Medicare may also require prior authorization for certain devices, necessitating additional documentation from the provider.

Your Financial Responsibility

When covered, orthotic inserts generally fall under Medicare Part B, which covers medical services and supplies. Beneficiaries must first meet the annual Part B deductible, which is $257 for 2025. After the deductible, Medicare Part B typically pays 80% of the Medicare-approved amount, and the beneficiary is responsible for the remaining 20% coinsurance.

If a supplier accepts “assignment,” they agree to the Medicare-approved amount as full payment and cannot bill the beneficiary for more than the deductible and coinsurance. If a supplier does not accept assignment, they may charge more, and the beneficiary could be responsible for the difference.

Supplemental insurance plans, such as Medigap policies or Medicare Advantage Plans (Part C), may help cover some or all of these out-of-pocket costs. Orthotics provided during a hospital or skilled nursing facility stay may be covered under Medicare Part A as part of inpatient charges.