Custom Fabricated Inserts - "An insert (A5513) is a total contact, custom fabricated, multiple density, removable inlay that is molded to a model of the patient's foot so that it conforms to the plantar surface and makes total contact with the foot, including the arch."
"A custom fabricated device is made from materials that do not have predefined trim lines for heel cup height, arch height and length, or toe shape." This means that a prefabricated insert can not be the starting point for a custom fabricated device.
"The insert must retain its shape during use for the life of the insert. The base layer of the device must be minimum of 3/16 inch of 35 Shore A material. The base layer is allowed to be thinner in the custom fabricated device because appropriate arch fill or other additional material will be layered up individually to maintain shape and achieve total contact and accommodate each patient's specific needs. The top layer of the device may be of a lower durometer and must be heat moldable. The materials used should be suitable with regards to the patient's condition."
Separate inserts may be covered and delivered independently of diabetic shoes if the supplier of the shoes verifies in writing that the patient has appropriate footwear into which the insert can be placed. This footwear must meet the definitions found in this policy for depth shoes or custom-molded shoes. Inserts used in non-covered shoes are non-covered.
Codes for inserts or modifications (A5503-A5511) may only be used for items related to diabetic shoes (A5500, A5501). They should not be used for items related to footwear coded with codes L3215-L3253. Inserts and modifications used with L coded footwear must be coded using L codes (L3000-L3649).
Inserts with a toe filler for missing toes or partial foot amputation should be code L5000 or L5999, whichever is applicable. For more information on toe fillers see insert accommodations and for billing information see reimbursement.