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Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that therapeutic shoes, inserts and/or modifications to therapeutic shoes are covered if all of the 
following criteria are met: 
 
1. The beneficiary has diabetes mellitus; and 
2. The certifying physician has documented in the beneficiary's medical record one or more of the following 
conditions: 
    a. Previous amputation of the other foot, or part of either foot, or 
    b. History of previous foot ulceration of either foot, or 
    c. History of pre-ulcerative calluses of either foot, or 
    d. Peripheral neuropathy with evidence of callus formation of either foot, or 
    e. Foot deformity of either foot, or 
    f. Poor circulation in either foot; and 
3. The certifying physician has certified that indications (1) and (2) are met and that he/she is treating the 
beneficiary under a comprehensive plan of care for his/her diabetes and that the beneficiary needs diabetic 
shoes. For claims with dates of service on or after 01/01/2011, the certifying physician must: 
     - Have an in-person visit with the beneficiary during which diabetes management is addressed within 6 
months prior to delivery of the shoes/inserts; and 
     - Sign the certification statement on or after the date of the in-person visit and within 3 months prior to 
delivery of the shoes/inserts. 
4. Prior to selecting the specific items that will be provided, the supplier must conduct and document an in-
person evaluation of the beneficiary.  
5. At the time of in-person delivery to the beneficiary of the items selected, the supplier must conduct an 
objective assessment of the fit of the shoe and inserts and document the results. A beneficiarys subjective 
statements regarding fit as the sole documentation of the in-person delivery does not meet this criterion. 
 
 If criteria 1-5 are not met, the therapeutic shoes, inserts and/or modifications will be denied as noncovered. 
When codes are billed without a KX modifier they will be denied as noncovered. 
 
In order to meet criterion 2, the certifying physician must either: 
1. Personally document one or more of criteria a  f in the medical record of an in-person visit within 6 
months prior to delivery of the shoes/inserts and prior to or on the same day as signing the certification 
statement; 
or 
2. Obtain, initial, date (prior to signing the certification statement), and indicate agreement with information 
from the medical records of an in-person visit with a podiatrist, other M.D or D.O., physician assistant, nurse 
practitioner, or clinical nurse specialist that is within 6 months prior to delivery of the shoes/inserts, and that 
documents one of more of criteria a  f. 
 
For beneficiaries meeting the coverage criteria, coverage is limited to one of the following within one calendar 
year (January  December): 
 - One pair of custom molded shoes (A5501) (which includes inserts provided with these shoes) and 2 
 additional pairs of inserts (A5512, A5513, or A5514); or 
 - One pair of depth shoes (A5500) and 3 pairs of inserts (A5512, A5513, or A5514) (not including the 
 non-customized removable inserts provided with such shoes). 
 
A modification of a custom molded or depth shoe may 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. You can find this 
information in the Local Coverage Article - Therapeutic Shoes for Persons with Diabetes (A52501). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.