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Medical Policies as defined by Medicare are provided on inserts, shoes, physicians and suppliers, and shoe modifications. Please use the links below for explicit information on each item.
- Medicare DMERC Medical Policy
- Diabetic Inserts
- Diabetic Shoes
- Physicians and Supplies
- Shoe Modifications
Diabetic Inserts
Diabetic Inserts SADMERC definition - For an insert to be covered by the benefit, it must be molded directly to the foot or a model of the foot, to the degree necessary to achieve total contact. To achieve total contact the device must be molded to come up to the arch while the foot is in a relatively uncompensated position. The position, length and height of the device’s arch must match that of the patient’s uncompensated arch.
Medicare defines a total contact insert as: "it makes and retains actual and continuous physical contact with the weight-bearing portions of the foot, including the arch throughout the standing and walking phases of gait."
Please click on the links below for additional information on each category.
Diabetic Insert Medical Policy released by Medicare on 3/08/2004
Prefabricated Inserts
Prefabricated Inserts - "An insert (A5512) is a total contact, multiple density, prefabricated removable inlay that isdirectly molded to the patient's foot. Direct molded means it has been conformed by molding directly to match the plantar surface of the individual patient's foot."
"The insert must retain its shape during use for the life of the insert. The layer responsible for shape retention is called the "base layer" in the code descriptor. This material usually constitutes the bottom layer of the insert and must be of a sufficient thickness and durometer to maintain its shape during use (i.e. 1/4 inch of 35 Shore A or 3/16 inch of 40 Shore A). The material responsible for maintaining the shape of the insert must be heat moldable. The full thickness of the base layer should extend from the heel through the arch. The base layer may taper beginning at the metatarsals and may be absent at the toes."
"The top layer(s) of the insert must also be heat moldable and are usually lower durometer. Modifications such as additional arch fill may be necessary to achieve and maintain total contact. The materials used should be suitable with regards to the patient's condition."
Practitioners must use an accepted molding technique to qualify for coverage. Heating the insert, placing iit in the shoe and having the patient stand on the insert is the same as compression molding. This technique does not adequately capture the shape of the plantar surface nor does it achieve total contact. Medicare has stated that compression molding is a non-covered service. Medicare has issued specific instructions and photographs of a molding techniques that qualify for coverage.
Custom Fabricated Inserts
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.
Diabetic Shoes
A depth shoe (A5500) must meet the following definition to qualify for the benefit category:
- Has a full length, heel-to-toe filler that when removed provides a minimum of 3/16" of additional depth used to accommodate custom-molded or customized inserts.
- Is made from leather or other suitable material of equal quality.
- Has some form of shoe closure.
- Is available in full and half sizes with a minimum of three widths so that the sole is graded to the size and width of the upper portions of the shoe according to the American standard last sizing schedule or its equivalent. (The American last sizing schedule is the numerical shoe sizing system used for shoes in the United States.) This includes a shoe with or without an internally seamless toe.
A custom-molded shoe (A5501) must meet the following definition to qualify for the benefit category:
- Is constructed over a positive model of the patient's foot.
- Is made from leather or other suitable material of equal quality.
- Has removable inserts that can be altered or replaced as the patient's condition warrants.
- Has some form of shoe closure. This includes a shoe with or without an internally seamless toe.
A custom molded shoe (A5501) is covered when the patient has a foot deformity, which cannot be accommodated by a depth shoe. The nature and severity of the deformity must be well documented in the supplier's records and may be requested by the DMERC. If there is insufficient justification for a custom molded shoe, but the general coverage criteria are met, payment will be based on the allowance for the least costly medically appropriate alternative, A5500.
Physician and Suppliers
The Certifying Physician provides the medical care for the beneficiary's diabetic condition. The certifying physician must be an M.D. or D.O., and may not be a podiatrist. The certifying physician (i.e., the physician who manages the systemic diabetic condition) may not furnish the footwear unless he/she practices in a defined rural area or a defined health professional shortage area.
The Prescribing Physician actually writes the order for the therapeutic shoe, modifications and inserts. The prescribing physician may be a podiatrist, M.D, or D.O. The particular type of footwear (shoes, inserts, modifications), which is necessary, must be prescribed by a podiatrist or other qualified physician, knowledgeable in the fitting of diabetic shoes and inserts. The prescribing physician (podiatrist or other qualified physician) can be the supplier (i.e., the one who furnishes the footwear).
The Supplier is the person or entity that actually fits and furnishes the shoe, modification, and/or insert to the beneficiary and then bills Medicare. The supplier may be a podiatrist, pedorthist, orthotist, prosthetist, or other qualified individual.
Shoe Modifications
Rigid rocker bottoms (A5503) are exterior elevations with apex position for 51 percent to 75 percent distance measured from the back end of the heel. The apex is a narrowed or pointed end of an anatomical structure. The apex must be positioned behind the metatarsal heads and tapering off sharply to the front tip of the sole. Apex height helps to eliminate pressure at the metatarsal heads. The steel in the shoe ensures rigidity. The heel of the shoe tapers off in the back in order to cause the heel to strike in the middle of the heel.
Roller bottoms (sole or bar) (A5503) are the same as rocker bottoms, but the heel is tapered from the apex to the front tip of the sole.
Wedges (posting) (A5504) are either of hind foot, fore foot, or both and may be in the middle or to the side. The function is to shift or transfer weight bearing upon standing or during ambulation to the opposite side for added support, stabilization, equalized weight distribution, or balance.
Metatarsal bars (A5505) are exterior bars, which are placed behind the metatarsal heads in order to remove pressure from the metatarsal heads. The bars are of various shapes, heights, and construction depending on the exact purpose.
Offset heel (A5506) is a heel flanged at its base either in the middle, to the side, or a combination, that is then extended upward to the shoe in order to stabilize extreme positions of the hind foot.
A Deluxe Feature (A5508) does not contribute to the therapeutic function of the shoe. It may include, but is not limited to style, color, or type of leather. A modification of a custom molded or depth shoe will be covered as a substitute for an insert. Although not intended as a comprehensive list, the following are the most common shoe modifications: rigid rocker bottoms (A5503), roller bottoms (A5503), wedges (A5504), metatarsal bars (A5505), or offset heels (A5506). Other modifications to diabetic shoes (A5507) include, but are not limited to, flared heels.
Deluxe features of diabetic shoes (A5508) will be denied as non-covered.