(Medicare Benefit Policy Manual)

Medicare does not cover cataract sunglasses obtained in addition to the regular (untinted) prosthetic lenses since the sunglasses duplicate the restoration of vision function performed by the regular prosthetic lenses.  2.  Payment for Intraocular Lenses (IOLs) Furnished in Ambulatory Surgical Centers (ASCs)   Effective for services furnished on or after March 12, 1990, payment for intraocular lenses (IOLs) inserted during or subsequent to cataract surgery in a Medicare certified ASC is included with the payment for facility services that are furnished in connection with the covered surgery.  Refer to the Medicare Claims Processing Manual, Chapter 14, Ambulatory Surgical Centers, for more information.  3.  Limitation on Coverage of Conventional Lenses   One pair of conventional eyeglasses or conventional contact lenses furnished after each cataract surgery with insertion of an IOL is covered.  C.  Dentures   Dentures are excluded from coverage.  However, when a denture or a portion of the denture is an integral part (built -in) of a covered prosthesis (e.g., an obturator to fill an opening in the palate), it is covered as part of that prosthesis.  D.  Supplies, Repairs, Adjustments, and Replacement   Supplies are covered that are necessary for the effective use of a prosthetic device (e.g., the batteries needed to operate an artificial larynx).  Adjustment of prosthetic devices required by wear or by a change in the patients condition is covered when ordered by a physician.  General provisions relating to the repair and replacement of durable medical equipment in 110.2 for the repair and replacement of prosthetic devices are applicable. (See the Medicare Benefit Policy Manual, Chapter 16, General Exclusions from Coverage, 40.4, for payment for devices replaced under a warranty.)  Replacement of conventional eyeglasses or contact lenses furnished in accordance with 120.B.3 is not covered.   Necessary supplies, adjustments, repairs, and replacements are covered even when the device had been in use before the user enrolled in Part B of the program, so long as the device continues to be medically required.   130 - Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes  (Rev. 1, 10- 01-03) B3-2133, A3- 3110.5, HO -228.5, AB -01-06 dated 1/18/01   These appliances are covered under Part B when furnished incident to physicians services or on a physicians order.  A brace includes rigid and semi -rigid devices which are used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body.  Elastic stockings, garter belts, and similar devices do not come within the scope of the definition of a brace.  Back braces include, but are not limited to, special corsets, e.g., sacroiliac , sacrolumbar, dorsolumbar corsets, and belts.  A terminal device (e.g., hand or hook) is covered under this provision whether an artificial limb is required by the patient. Stump stockings and harnesses (including replacements) are also covered when these  appliances are essential to the effective use of the artificial limb.   Adjustments to an artificial limb or other appliance required by wear or by a change in the patients condition are covered when ordered by a physician.  Adjustments, repairs and replacements are covered even when the item had been in use before the user enrolled in Part B of the program so long as the device continues to be medically required.  140 - Therapeutic Shoes for Individuals with Diabetes  (Rev. 241, Issued: 02-02-18, Effective: 04-01-18, Implementation: 04-02-18)  Coverage of therapeutic shoes (depth or custom-molded) along with inserts for individuals with diabetes is available as of May 1, 1993.  These diabetic shoes are covered if the requirements as specified in this section concerning certification and prescrip tion are fulfilled.  In addition, this benefit provides for a pair of diabetic shoes even if only one foot suffers from diabetic foot disease.  Each shoe is equally equipped so that the affected limb, as well as the remaining limb, is protected.  Claims fo r therapeutic shoes for diabetics are processed by the Durable Medical Equipment Medicare Administrative Contractors (DME MACs).   Therapeutic shoes for diabetics are not DME and are not considered DME nor orthotics, but a separate category of coverage under Medicare Part B. (See 1861(s)(12) and 1833(o)  of the Act.)  A.  Definitions   The following items may be covered under the diabetic shoe benefit:  1.  Custom- Molded Shoes   Custom-molded shoes are shoes that:   Are constructed over a positive model of the patients foot;   Are made from leather or other suitable material of equal quality;   Have removable inserts that can be altered or replaced as the patients condition warrants; and   Have some form of shoe closure.   2.  Depth Shoes   Depth shoes are shoes that:    Have a full length, heel -to-toe filler that, when removed, provides a minimum of 3/16 inch of additional depth used to accommodate custom -molded or customized inserts;   Are made from leather or other suitable material of equal quality;   Have some form of shoe closure; and    Are available in full and half sizes with a minimum of three widths so that the sole is graded to the size and width of the upper portions of the shoes according to the American standard last sizing schedule or its equivalent. (The American standard last s izing schedule is the numerical shoe sizing system used for shoes sold in the United States.)   3.  Inserts  Inserts are total contact, multiple density, removable inlays that are directly molded to the patients foot or a model of the patients foot or directly carved from a patient -specific, rectified electronic model and that are made of a suitable material wi th regard to the patients condition.   B.  Coverage   1.  Limitations   For each individual, coverage of the footwear and inserts is limited to one of the following within one calendar year:    No more than one pair of custom -molded shoes (including inserts provided with such shoes) and two additional pairs of inserts; or    No more than one pair of depth shoes and three pairs of inserts (not including the noncustomized removable inserts provided with such shoes).  2.  Coverage of Diabetic Shoes and Brace  Orthopedic shoes, as stated in the Medicare Claims Processing Manual, Chapter 20, Durable Medical Equipment, Surgical Dressings and Casts, Orthotics and Artificial Limbs, and Prosthetic Devices, generally are not covered.  This exclusion does not apply to orthopedic shoes that are an integral part of a leg brace.  In situations in which an individual qualifies for both diabetic shoes and a leg brace, these items are covered separately.  Thus, the diabetic shoes may be covered if the requirements for this section are met, while the brace may be covered if the requirements of 130 are met.    3.  Substitution of Modifications for Inserts   An individual may substitute modification(s) of custom -molded or depth shoes instead of obtaining a pair(s) of inserts in any combination.  Payment for the modification(s) may not exceed the limit set for the inserts for which the individual is entitled.  The following is a list of the most common shoe modifications available, but it is not meant as an exhaustive list of the modifications available for diabetic shoes:   Rigid Rocker Bottoms  - These are exterior elevations with apex positions for 51 percent to 75 percent distance measured from the back end of the heel.  The apex is a narrowed or pointed end of an anatomical structure.  The apex must be positioned behind the metatarsal heads and tapered off sharply to the front tip of the sole.  Apex height helps to eliminate pressure at the metatarsal heads. Rigidity is ensured by the steel in the shoe.  The heel of the shoe tapers off in the back in order to cause the heel  to strike in the middle of the heel;   Roller Bottoms (Sole or Bar)  - These are the same as rocker bottoms, but the heel is tapered from the apex to the front tip of the sole;   Metatarsal Bars  - An exterior bar is placed behind the metatarsal heads in order to remove pressure from the metatarsal heads.  The bars are of various shapes, heights, and construction depending on the exact purpose;   Wedges (Posting)  - Wedges are either of hind foot, fore foot, or both and may be in the middle or to the side.  The function is to shift or transfer weight bearing upon standing or during ambulation to the opposite side for added support, stabilization, equalized weight distribution, or balance; and    Offset Heels  - This is a heel flanged at its base either in the middle, to the side, or a combination, that is then extended upward to the shoe in order to stabilize extreme positions of the hind foot.  Other modifications to diabetic shoes include, but are not limited to flared heels, Velcro closures, and inserts for missing toes.  4.  Separate Inserts   Inserts may be covered and dispensed independently of diabetic shoes if the supplier of the shoes verifies in writing that the patient has appropriate footwear into which the insert can be placed.  This footwear must meet the definitions found above for depth shoes and custom -molded shoes.  C.  Certification   The need for diabetic shoes must be certified by a physician who is a doctor of medicine or a doctor of osteopathy and who is responsible for diagnosing and treating the patients diabetic systemic condition through a comprehensive plan of care.  This mana ging physician must:    Document in the patients medical record that the patient has diabetes;    Certify that the patient is being treated under a comprehensive plan of care for diabetes, and that the patient needs diabetic shoes; and    Document in the patients record that the patient has one or more of the following conditions:   o Peripheral neuropathy with evidence of callus formation;   o History of pre -ulcerative calluses;   o History of previous ulceration;   o Foot deformity;   o Previous amputation of the foot or part of the foot; or   o Poor circulation.   D.  Prescription   Following certification by the physician managing the patients systemic diabetic condition, a podiatrist or other qualified physician who is knowledgeable in the fitting of diabetic shoes and inserts may prescribe the particular type of footwear necessary .  E.  Furnishing Footwear   The footwear must be fitted and furnished by a podiatrist or other qualified individual such as a pedorthist, an orthotist, or a prosthetist.  The certifying physician may not furnish the diabetic shoes unless the certifying physician is the only qualified individual in the area.  It is left to the discretion of each A/B MAC (B) to determine the meaning of in the area.   150 - Dental Services  (Rev.  11995; Issued: 04- 21-23; Effective: 01 -01-23; Implementation: 05 -12-23)  As indicated under the general exclusions from coverage in 42 CFR 411.15(i), and subject to exceptions, items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth are not  covered. Structures directly supporting the teeth means the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. Two statutory exceptions to this policy allow for Medicare payment for inpatient hospital services in connection with the provision of dental services if the individual, because of the individuals underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospita lization in connection with the provision of such services.   There are some other instances where medical services necessary to diagnose and treat the individuals underlying medical condition may require the performance of certain dental services and the dental exclusion may not apply. Dental services that are inextricably linked to, and substantially related and integral to the clinical success of, certain covered medical services are not excluded. Such non- excluded dental services could include dental and oral examinations as well as medically necessary diagnostic and treatment services to eliminate an oral or dental infection. We note that the necessary treatment to eradicate an infection may not include the totality of recommended dental services for a given patient. For example, if an infected tooth is identified in a patient requiring  an organ transplant, cardiac valve replacement, or valvuloplasty procedure, the necessary treatment would be to eradicate the infection, which could result in the tooth being extracted. Additional dental services, such as a dental implant or crown, may not be considered immediately necessary to eliminate or eradicate the infection or its source prior to surgery. Therefore, such additional services would not be inextricably linked to, and substantially related and integral to the clinical success of, the or gan transplant, cardiac valve replacement, or valvuloplasty services. As such, no Medicare payment would be made for the additional services that are not immediately necessary prior to surgery to eliminate or eradicate the infection.