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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 shoes, inserts, and modifications are covered in limited circumstances. They are covered in 
selected beneficiaries with diabetes for the prevention or treatment of diabetic foot ulcers. However, different 
codes are used for footwear provided under this benefit. See the medical policy on Therapeutic Shoes for 
Persons with Diabetes for details. 
 
Shoes are also covered if they are an integral part of a covered leg brace described by codes L1900, L1920, 
L1980, L1990, L2000, L2005, L2010, L2020, L2030, L2050, L2060, L2080, or L2090. Oxford shoes (L3224, 
L3225) are covered in these situations. Other shoes, e.g. high top, depth inlay or custom for non-diabetics, etc. 
(L3649), are also covered if they are an integral part of a covered brace and if they are medically necessary for 
the proper functioning of the brace. Heel replacements (L3455, L3460), sole replacements (L3530, L3540), and 
shoe transfers (L3600, L3610, L3620, L3630 and L3640) involving shoes on a covered brace are also covered. 
Inserts and other shoe modifications (L3000, L3001, L3002, L3003, L3010, L3020, L3030, L3031, L3040, 
L3050, L3060, L3070, L3080, L3090, L3100, L3140, L3150, L3160, L3170, L3300, L3310, L3320, L3330, 
L3332, L3334, L3340, L3350, L3360, L3370, L3380, L3390, L3400, L3410, L3420, L3430, L3440, L3450, 
L3465, L3470, L3480, L3485, L3500, L3510, L3520, L3550, L3560, L3570, L3580, L3590 and L3595) are 
covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for 
the proper functioning of the brace. Shoes and related modifications, inserts, heel/sole replacements or shoe 
transfers billed without a KX modifier will be denied as noncovered because coverage is statutorily excluded. 
 
According to a national policy determination, a shoe and related modifications, inserts, and heel/sole 
replacements, are covered only when the shoe is an integral part of a brace. A matching shoe which is not 
attached to a brace and items related to that shoe must not be billed with a KX modifier and will be denied as 
noncovered because coverage is statutorily excluded. 
 Shoes which are incorporated into a brace must be billed by the same supplier billing for the brace. Shoes 
which are billed separately (i.e., not as part of a brace) will be denied as noncovered. A KX modifier must not 
be used in this situation. 
 
Shoes are denied as noncovered when they are put on over a partial foot prosthesis or other lower extremity 
prosthesis (L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, 
L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5400, L5410, L5420, L5430, L5450, L5460, 
L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595 and 
L5600) which is attached to the residual limb by other mechanisms because there is no Medicare benefit for 
these items. 
 
A foot pressure off-loading/ supportive device (A9283) is denied as noncovered because there is no Medicare 
benefit category for these items. 
 
With the exception of the situations described above, orthopedic footwear billed using codes L3000, L3001, 
L3002, L3003, L3010, L3020, L3030, L3031, L3040, L3050, L3060, L3070, L3080, L3090, L3100, L3140, 
L3150, L3160, L3170, L3201, L3202, L3203, L3204, L3206, L3207, L3208, L3209, L3211, L3212, L3213, 
L3214, L3215, L3216, L3217, L3219, L3221, L3222, L3224, L3225, L3230, L3250, L3251, L3252, L3253, 
L3254, L3255, L3257, L3260, L3265, L3300, L3310, L3320, L3330, L3332, L3334, L3340, L3350, L3360, 
L3370, L3380, L3390, L3400, L3410, L3420, L3430, L3440, L3450, L3455, L3460, L3465, L3470, L3480, 
L3485, L3500, L3510, L3520, L3530, L3540, L3550, L3560, L3570, L3580, L3590, L3595, L3600, L3610, 
L3620, L3630, L3640, and L3649 will be denied as noncovered. 
 
You can find this information in the Local Coverage Article (LCA) Standard Documentation Requirements for 
Orthopedic Footwear (A52481). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.