Does Medicare Pay for Diabetic and Therapeutic Shoes?

Medicare provides health coverage, which includes certain durable medical equipment (DME) and specific medical supplies. Coverage for footwear is not universal and has particular conditions. Therapeutic shoes, often called diabetic shoes, are covered under Medicare Part B, not as DME, but as a distinct benefit designed to prevent serious foot complications. This specialized coverage ensures access to medically necessary footwear for individuals with specific health conditions.

Types of Covered Footwear and Inserts

Medicare may cover specific categories of footwear and inserts when medically necessary. Therapeutic shoes, commonly called diabetic shoes, protect the feet, minimize pressure points, and prevent lower-limb ulcers and amputations for people with diabetes. These shoes incorporate extra depth to comfortably accommodate specialized inserts, helping to manage foot health. Despite their medical purpose, many therapeutic shoes are styled to resemble conventional footwear.

Among the covered types are extra-depth shoes, which are wider and deeper than standard shoes, providing ample space for foot deformities and inserts. Custom-molded shoes offer a tailored solution, crafted from a precise model of an individual’s foot. These shoes are typically covered when a foot deformity is severe and cannot be adequately accommodated by an extra-depth shoe. Both extra-depth and custom-molded shoes feature removable inserts and a secure closure mechanism.

Inserts play an important role in redistributing pressure and supporting the foot. Medicare covers total contact, multiple density, and removable inlay inserts that are either directly molded to the patient’s foot or carved from a patient-specific model. These inserts are made from materials suitable for the patient’s condition. Additionally, Medicare may cover certain shoe modifications as an alternative to separate inserts.

Medicare Coverage Criteria

Medicare coverage for therapeutic footwear and inserts depends on specific medical criteria. An individual must have diabetes mellitus and one or more qualifying foot conditions in either or both feet. These conditions include:

• A history of partial or complete foot amputation
• Previous foot ulceration
• Pre-ulcerative calluses
• Nerve damage (neuropathy) with evidence of callus formation
• Poor circulation
• A foot deformity

The involvement of a physician is a primary requirement for coverage. A certifying physician, an MD or DO, is responsible for managing the patient’s systemic diabetic condition under a comprehensive care plan. This physician must document the patient’s diabetes and certify the medical necessity for therapeutic shoes and/or inserts. An in-person visit with this certifying physician is required within six months prior to the delivery of the footwear. The certification statement must be signed on or after this visit and within three months before the shoes are dispensed.

Following the certifying physician’s assessment, a prescribing practitioner writes the specific order for the footwear. This practitioner can be the certifying physician, a podiatrist, physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist. Medicare sets frequency limits for coverage. Eligible individuals can receive one pair of therapeutic shoes (either extra-depth or custom-molded) per calendar year. For extra-depth shoes, three pairs of inserts are covered annually, while custom-molded shoes include two additional pairs of inserts beyond those provided with the shoes.

Obtaining Covered Footwear

Acquiring Medicare-covered therapeutic footwear involves a structured process. After the necessary medical documentation and prescription are in place, the next step is to obtain the footwear from a Medicare-approved supplier. These suppliers are classified as Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) providers and must adhere to strict enrollment and quality standards set by Medicare. It is important to confirm that the chosen supplier is enrolled with Medicare to ensure coverage.

The supplier is responsible for providing a proper fitting of the therapeutic shoes and inserts. They are required to conduct an objective assessment of the fit and document the results. Medicare Part B generally covers 80% of the Medicare-approved amount for therapeutic shoes and inserts, after the annual Part B deductible has been met. The patient is then responsible for the remaining 20% coinsurance. Medicare Advantage (Part C) plans also offer this coverage, though specific out-of-pocket costs like premiums, deductibles, and coinsurance can vary depending on the individual plan.