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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 state that the Certifying Physician is defined as a doctor of medicine (M.D.) or a doctor 
of osteopathy (D.O.) who is responsible for diagnosing and treating the beneficiary's diabetic 
systemic condition through a comprehensive plan of care. The certifying physician may not be a 
podiatrist or clinical nurse specialist.
Consequent to the M.D. or D.O. restriction, a nurse practitioner (NP) and a physician assistant 
(PA) may not serve in the role of the certifying physician, unless practicing "incident to" the 
supervising physician's authority, as described below.

NPs or PAs providing ancillary services as auxiliary personnel could meet the "incident to" 
requirements in their provision of therapeutic shoes to beneficiaries with diabetes if all of the 
following criteria are met:

1. The supervising physician has documented in the medical record that the patient is diabetic and 
has been, and continues to provide, the patient follow-up under a comprehensive management program 
of that condition; and,
2. The NP or PA certifies that the provision of the therapeutic shoes is part of the comprehensive 
treatment plan being provided to the patient; and,
3. The supervising physician must review and verify (sign and date) all of the NP or PA notes in 
the medical record pertaining to the provision of the therapeutic shoes, acknowledging their 
agreement with the actions of the NP or PA.

In states where the NP may practice independently, the NP's employment situation would require 
compliance with Medicare "incident to" rules in order to serve as the certifying physician. Please 
refer to the applicable A/B MAC for further information.

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.
4. 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.)
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 
beneficiary's 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.

You can find this 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.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.