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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 the Prescribing Practitioner is the person who actually writes the order for the therapeutic shoe, 
modifications and inserts. This practitioner must be knowledgeable in the fitting of diabetic shoes and inserts. The 
prescribing practitioner may be a podiatrist, M.D., D.O., physician assistant, nurse practitioner, or clinical nurse 
specialist. The prescribing practitioner may be the supplier (i.e., the one who furnishes the footwear).  
 
The Supplier is the person or entity that actually furnishes the shoe, modification, and/or insert to the beneficiary 
and that bills Medicare. The supplier may be a podiatrist, pedorthist, orthotist, prosthetist or other qualified 
individual. The Prescribing Practitioner may be the supplier. The Certifying Physician may only be the supplier if 
the certifying physician is practicing in a defined rural area or a defined health professional shortage area.  
 
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 (Reference diagnosis code section below); 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 (refer to the Policy Specific Documentation Requirements section below) on or  
      after the date of the in-person visit and within 3 months prior to delivery of the shoes/inserts.  
      1. Prior to selecting the specific items that will be provided, the supplier must conduct and document an in- 
          person evaluation of the beneficiary. (Refer to the Policy Specific Documentation Requirements section  
          below.)  
          2. 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 (see Policy Specific Documentation Requirements section below), they will 
be denied as noncovered.  
 
In order to meet criterion 2, the certifying physician must either:  
i. 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  
ii. 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. The requirement that the 
in-person visit(s) be within 6 months prior to delivery of the shoes/inserts is effective for claims with 
dates of service on or after 1/1/2011.  
 
Note: The certification statement is not sufficient to meet the requirement for documentation in the medical record.  
 
Depending on the items ordered, both the evaluation and delivery could occur on the same day if the supplier had 
both a sufficient array of sizes and types of shoes/inserts and adequate equipment on site to provide the items that 
meet the beneficiarys needs. Both components of the visit (criteria 4 and 5 above) must be clearly documented.  
 
For claims with dates of service on or after 1/1/2011, there must be an in-person visit with the prescribing 
practitioner within 6 months prior to delivery of the shoes/inserts.  
 
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.  
 
Quantities of shoes, inserts, and/or modifications greater than those listed above will be denied as noncovered.  
 
Items represented by code A5510 reflect compression molding to the beneficiary's foot over time through the heat 
and pressure generated by wearing a shoe with the insert present. Since these inserts are not considered total contact 
at the time of dispensing, they do not meet the requirements of the benefit category and will be denied as 
noncovered.  
 
Inserts used in noncovered shoes are noncovered.  
 
Deluxe features of diabetic shoes (A5508) will be denied as noncovered. 
 
There is no separate payment for the fitting of the shoes, inserts or modifications or for the certification of need or 
prescription of the footwear. Claims for unrelated evaluation and management services provided by the practitioner 
are processed by the local carrier.  Shoes are also covered if they are an integral part of a covered leg brace. However, different codes are used for 
footwear provided under this benefit. See the medical policy on Orthopedic Footwear for details.  
 
You can find this information in the Local Coverage Article Therapeutic Shoes for Persons with Diabetes - Policy 
Article (A52501). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.