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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 state that for any item to be covered by Medicare, it must 1) be eligible for a defined Medicare 
benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve 
the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and 
regulatory requirements. Information provided in this policy article relates to determinations other than those 
based on Social Security Act 1862(a)(1)(A) provisions (i.e. "reasonable and necessary"). Orthopedic footwear 
is covered under the leg, arm, back, and neck braces, and artificial legs, arms and eyes benefit (Social Security 
Act 1861(s)(9)). In order for a beneficiary's DME to be eligible for reimbursement, the reasonable and 
necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, 
there are specific statutory payment policy requirements, discussed below, that also must be met. 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 rule at the Medicare Local Coverage Article (LCA)- A52481, Orthopedic Footwear - Policy 
Article. 
 
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.