Does Medicare Cover Orthotics for Plantar Fasciitis?

Plantar fasciitis, a common cause of heel pain, often prompts individuals to explore various treatment options, including orthotics. For those enrolled in Medicare, understanding coverage for such devices can be complex. This article clarifies how Medicare addresses orthotics for plantar fasciitis, detailing general coverage rules, eligibility, the process for obtaining items, financial responsibilities, and the claims procedure.

Medicare’s General Orthotics Coverage

Medicare Part B provides coverage for certain orthotic devices when medically necessary. These devices, often classified as Durable Medical Equipment (DME), are external supports like braces that assist a weak or injured body part. To qualify for coverage, an orthotic must be a rigid or semi-rigid device intended to support, align, prevent, or correct deformities, or to restrict motion in an affected area.

Medicare’s criteria for DME coverage require that the equipment can withstand repeated use, serves a medical purpose, and is not generally useful to someone without an illness or injury. It must also be appropriate for use in the home. Therapeutic shoes and inserts for individuals with diabetes and severe diabetes-related foot disease are specifically covered under Part B, even if not strictly categorized as DME.

A qualified healthcare provider, such as a physician, must prescribe any orthotic device for it to be covered. This prescription establishes the medical necessity for the device, linking it directly to the diagnosis or treatment of a specific medical condition.

Orthotics Coverage for Plantar Fasciitis

When considering orthotics for plantar fasciitis, Medicare’s coverage hinges on the medical necessity of custom-molded or custom-fabricated devices. Unlike over-the-counter shoe inserts, which are typically not covered as they are considered primarily for comfort, custom orthotics may be covered if a physician determines them necessary for treatment. This medical necessity often arises when conservative treatments have been unsuccessful or the condition is severe.

The key distinction is that the orthotic must be an integral part of a treatment plan to address a diagnosed medical issue, rather than just general foot support.

The physician’s documentation must clearly support the need for custom orthotics, outlining why these specific devices are required for the patient’s condition. This often includes details about the severity of plantar fasciitis and how the custom orthotics will address functional limitations or pain.

How to Obtain Covered Orthotics

To obtain Medicare-covered orthotics, an individual must first consult with a qualified healthcare professional. This could be a podiatrist, orthopedist, or another physician who can diagnose plantar fasciitis and confirm the medical necessity of custom orthotics.

Upon determining medical necessity, the physician must provide a detailed prescription or order for the orthotics. This document should include the specific diagnosis, the type of orthotic required (e.g., custom-molded foot orthotics), and a clear medical justification for its use. This prescription must be obtained before the orthotics are provided, as Medicare requires prior authorization or a valid order predating the service.

Next, individuals must locate a supplier that is enrolled in Medicare and accepts assignment. Medicare’s website offers a search tool to find approved Durable Medical Equipment (DME) suppliers. Verifying that a supplier participates in Medicare and accepts assignment is important because it directly impacts out-of-pocket costs and ensures Medicare will process the claim.

Your Financial Responsibility

When Medicare Part B covers orthotics, individuals incur certain financial responsibilities. After meeting the annual Medicare Part B deductible, which is $257 in 2025, patients are responsible for 20% of the Medicare-approved amount for the orthotics. Medicare pays the remaining 80% of the approved cost.

Accepting assignment is important. If a Medicare-enrolled supplier accepts assignment, they agree to accept the Medicare-approved amount as full payment for the orthotics. This means they can only charge the patient the deductible (if not yet met) and the 20% coinsurance. If a supplier does not accept assignment, they are permitted to charge more than the Medicare-approved amount, and the patient becomes responsible for the difference, in addition to the standard coinsurance and deductible.

For individuals enrolled in Medicare Advantage plans (Part C), the financial responsibilities may vary. Medicare Advantage plans are required to cover at least what Original Medicare covers, but they may have different cost-sharing rules, deductibles, coinsurance, or copayments. Consult your plan’s documents or contact the plan provider to understand out-of-pocket costs for orthotics under a Medicare Advantage plan.

Understanding the Claims Process

Once orthotics have been obtained from a Medicare-enrolled supplier, the supplier is responsible for submitting the claim to Medicare. This process ensures Medicare receives all necessary information, including the physician’s order and documentation of medical necessity, to process the payment. Patients do not need to submit claims themselves when using participating providers.

After Medicare processes the claim, an Explanation of Benefits (EOB) will be sent to the individual. The EOB is not a bill but a summary detailing the services billed, the amount Medicare approved, the amount Medicare paid, and the amount the patient may owe. Reviewing the EOB can help individuals understand how their claim was processed and identify any discrepancies.

If a claim for orthotics is denied, individuals have the right to appeal the decision. The Medicare appeals process involves several levels. The first level is a Redetermination, followed by a Reconsideration by an independent review entity (like Maximus for DME claims). Further appeal levels include a hearing before an Administrative Law Judge (ALJ), review by the Medicare Appeals Council, and finally, judicial review in federal court if the amount in controversy meets the threshold.