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Trained Horton staff members are adept in creating footwear solutions for problem feet. We may advise a variety of approaches, from molded shoe inserts to extra-depth or other variations of orthopedic shoes. Furthermore, our pedorthists can design shoe modifications, postsurgical footwear, and other custom foot orthoses such as toe
fillers.
Years of clinical and laboratory experience combined with intensive research and experimentation, plus formal orthotic and prosthetic education and training make Horton's Orthotic Lab practitioners exceptionally qualified in our field of expertise. Our staff includes prosthetic, orthotic, and fabrication technicians who are accredited by the America Board for Certification in Orthotics and Prosthetics (ABC), testifying to the high level of care which we provide to all types of patients.
MEDICAL POLICY
BENEFIT CATEGORY: Therapeutic Shoes for Diabetics
DEFINITIONS
A depth shoe (A5500) is one that 1) has a full length, heel-to-toe filler that when removed provides a minimum of 3/16" of additional depth used to accommodate custom-molded or customized inserts;
2) is made from leather or other suitable material of equal quality; 3) has some form of shoe closure and 4) is 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 shoe according to the American standard last sizing schedule or its equivalent. (The American last sizing schedule is the numerical shoe sizing system used for shoes in the United States.) This
includes a shoe with or without an internally seamless toe.
A custom-molded shoe (A5501) is one that 1) is constructed over a positive model of the patient's foot, 2) is made from leather or other suitable material of equal quality, 3) has removable inserts that
can be altered or replaced as the patient's condition warrants and 4) has some form of shoe closure. This includes a shoe with or without an internally seamless toe.
An insert (A5502) is a total contact, multiple density, removable inlay that is directly molded to the patient's foot or a model of the patient's foot and that is made of a suitable material with regard
to the patient's condition.
Rigid rocker bottoms (A5503) are exterior elevations with apex position 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 tapering 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) (A5503) are the same as rocker bottoms, but the heel is tapered from the apex to the front tip of the sole.
Wedges (posting) (A5504) 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.
Metatarsal bars (A5505) are exterior bars which are 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.
Offset heel (A5506) 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.
A deluxe feature (K0401) does not contribute to the therapeutic function of the shoe. It may include, but is not limited to style, color, or type of leather.
The Certifying Physician provides the medical care for the beneficiary's diabetic condition. The certifying physician must be an M.D. or D.O., and may not be a podiatrist.
The Prescribing Physician actually writes the order for the therapeutic shoe, modifications and inserts. The prescribing physician may be a podiatrist, M.D, or D.O.
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 physician 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.
COVERAGE AND PAYMENT RULES
Diabetic shoes, inserts and/or modifications to the shoes are covered if the following criteria are met:
1) The patient has diabetes mellitus
2) The patient has 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
3) The certifying physician who is managing the patient's systemic diabetes condition has certified that indications (1) and (2) are met and that he/she is treating the patient under a
comprehensive plan of care for his/her diabetes and that the patient needs diabetic shoes.
For patients meeting these criteria, coverage is limited to one of the following within one calendar year:
1) One pair of custom molded shoes (A5501) (which includes inserts provided with these shoes) and 2 additional pairs of inserts (A5502).
2) One pair of depth shoes (A5500) and 3 pairs of inserts (A5502) (not including the non-customized removable inserts provided with such
shoes).
Separate 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 in this policy for depth shoes or custom-molded shoes. In addition, the inserts furnished must fully meet the definition of an insert set forth in this
policy. Inserts which will be used in noncovered shoes are noncovered.
A custom molded shoe (A5501) is covered when the patient has a foot deformity which cannot be accommodated by a depth shoe. The nature and severity of the
deformity must be well documented in the supplier's records and may be requested by the DMERC. If there is insufficient justification for a custom molded shoe but the general coverage criteria are met, payment will be based
on the allowance for the least costly medically appropriate alternative, A5500.
A modification of a custom molded or depth shoe will 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 and inserts for missing toes. Deluxe features of diabetic shoes (K0401) will be denied as
noncovered.
Shoes, inserts, and/or modifications that are provided to patients who do not meet the coverage criteria will be denied as noncovered. When codes are billed without a ZX modifier (see
Documentation section), they will be denied as noncovered.
The particular type of footwear (shoes, inserts, modifications) which is necessary must be prescribed by a podiatrist or other qualified physician, knowledgeable in the fitting of
diabetic shoes and inserts. The footwear must be fitted and furnished by a podiatrist or other qualified individual such as a pedorthist, orthotist or prosthetist. The certifying physician (i.e. the physician who manages the
systemic diabetic condition) may not furnish the footwear unless he/she practices in a defined rural area or a defined health professional shortage area. The prescribing physician (podiartrist or other qualified physician)
can be the supplier (i.e. the one who furnishes the footwear).
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. Unrelated evaluation and
management services by the physician are processed by the local carrier.
DOCUMENTATION
An order for the shoes, inserts or modifications which has been signed and dated by the prescribing physician must be kept on file by the supplier. If the prescribing physician is the
supplier, a separate order is not required, but the item provided must be clearly noted in the patient's record. A new order is not required for the replacement of an insert or modification within one year of the order on
file. However the supplier's records should document the reason for the replacement. A new order is required for the replacement of any shoe. A new order is also required for the replacement of an insert or modification more
than one year from the most recent order on file.
The supplier must obtain a signed statement from the certifying physician specifying that the patient has diabetes mellitus, has one of conditions 2a-2f listed in the policy, is being
treated under a comprehensive plan of care for his/her diabetes, and needs diabetic shoes. The Statement of Certifying Physician for Therapeutic Shoes developed by the DMERC is recommended. This statement may be completed by
the prescribing physician or supplier but must be reviewed for accuracy of the information and signed by the certifying physician to indicate agreement. A new Certification Statement is required for a shoe, insert or
modification provided more than one year from the most recent Certification Statement on file. If the supplier has a current signed statement on file that indicates that the coverage criteria described above have been met,
then a ZX modifier must be added to the code. A diagnosis code for diabetes (ICD-9 250.00- 250.91) should be entered on the claim.
| HCPCS CODES |
The appearance of a code in this section does not necessarily indicate coverage. |
| A5500 |
For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density
insert(s), per shoe |
| A5501 |
For diabetics only, fitting (including follow-up), custom preparation and supply of shoe molded from cast(s) of patient's foot (custom molded shoe), per shoe |
| A5502 |
For diabetics only, multiple density insert(s), per shoe |
| A5503 |
For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom- molded shoe with roller or rigid rocker bottom, per shoe |
| A5504 |
For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom- molded shoe with wedge(s), per shoe |
| A5505 |
For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom- molded shoe with metatarsal bar, per shoe |
| A5506 |
For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom- molded shoe with off-set heel(s), per shoe |
| A5507 |
For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth- inlay shoe or custom-molded shoe, per shoe |
| K0401 |
For diabetics only, deluxe feature of off-the-shelf depth inlay shoe or custom molded shoe,
per shoe |
| ZX |
Specific requirements found in the documentation section of the medical policy have been met and evidence of this is available in the supplier's record |
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