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End User Agreements for Providers
Some of the Provider information contained on the Noridian Medicare web site is copyrighted by the American Medical Association, the American Dental Association, and/or the American Hospital Association. This includes items such as CPT codes, CDT codes, ICD-10 and other UB-04 codes.
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Consent to Monitoring
When Should You Stop Wearing Orthotics
If your healthcare provider has recommended medication or treatment for you, you should always discuss your concerns with them before stopping. This even applies to orthotics. You may only require orthotics for a certain period to correct a problem, or it could be something you need permanently. If your orthotic becomes uncomfortable or doesnt seem to be doing much to help you, talk to the provider who fitted you for the orthotic. You may require adjustments or a new device altogether.
What extra benefits and savings do you qualify for?
Plans That Do Not Exclude Foot Orthotics
Note: For plans that do not exclude coverage of foot orthotics, Aetna covers foot orthotics when the medical necessity criteria below are met. Please check benefit plan descriptions.
Foot orthotics are considered medically necessary for members who meet all of the following selection criteria:
Member has any of the following conditions:
Foot orthotics have no proven value for back pain, knee pain , pes planus , pronation, corns and calluses, hip osteoarthritis, and lower leg injuries
The member must have symptoms associated with the particular foot condition and
The member has failed to respond to a course of appropriate conservative treatment . Orthotics should not be considered first line therapy.
Foot orthotics are considered experimental and investigational when these criteria are not met and for treatment of joint hypermobility syndrome.
The following types of foot orthotics are considered medically necessary for the above listed indications:
One of the following per member per calendar year is considered medically necessary:
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How Much Do Custom Orthotic Inserts Cost
Custom-molded shoes and inserts can cost hundreds of dollars per pair. While this might seem a lot more expensive than over-the-counter manufactured options, the cost isnt that much different when you factor in Medicare or insurance coverage. A custom pair of orthotic shoes can cost between $400 and $600. Medicare beneficiaries will pay 20% of the cost after meeting their annual deductible, and Medicare will pay 80%. This means that for a $600 orthotic, you would pay $120, while Medicare pays $480, if you have already satisfied your Part B deductible.
Does Medicare Cover Orthopedic Shoes
Medicare coverage of orthopedic shoes is generally limited to people with diabetes and severe diabetic foot disease. Medicare Part B may cover the fitting and purchase of either one pair of custom-molded orthopedic shoes and inserts each calendar year or one pair of extra-depth orthopedic shoes each calendar year. Medicare may also cover shoe modifications instead of inserts. In addition, Medicare may cover two additional pairs of inserts each calendar year for custom-molded shoes and three pairs of inserts each calendar year for extra-depth shoes. Even if you have diabetes, a doctor such as a podiatrist, must certify that you need orthopedic shoes or inserts. Further, your orthopedic shoes or inserts must be supplied by an orthotist, prosthetist, pedorthist or other qualified individual trained in treatment of the conditions of the foot and ankle.
If your supplier accepts Medicare assignment, you generally pay 20% of the Medicare-approved amount and the Medicare Part B deductible applies. Your doctors and suppliers also must be enrolled in Medicare for Medicare to provide coverage for your orthopedic shoes.
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Medicare Advantage Coverage For Various Types Of Orthotics
Did you know you can get your Medicare Part B benefits through a type of Medicare plan thats available through private, Medicare-approved insurance companies? The program is called Medicare Advantage, or Medicare Part C, and its another way to get your Medicare coverage. Many Medicare Advantage plans even include prescription drug coverage thats something for which Original Medicare, Part A and Part B, offers only limited coverage, typically not extending to the prescription medications you take at home. There may be a choice of Medicare Advantage plans available in your area. You need to continue paying your Part B premium when you have a Medicare Advantage plan, along with any premium the plan may charge.
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This website and its contents are for informational purposes only. Nothing on this website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.
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Medicare’s Therapeutic Shoe Benefit
The Centers for Disease Control and Prevention estimates that 23.1-million Americans have been diagnosed with diabetes. Studies have shown that 25 percent of persons with diabetes develop foot problems related to the disease and that up to 15 percent of persons with diabetes develop foot ulcers.
Since 1993, Medicare has covered certain therapeutic shoes, inserts and modifications for persons with diabetes who meet specified qualifying requirements.
Medicare covers diabetic shoes, inserts and modifications for program beneficiaries only if the following criteria are met*:
The patient has diabetes and one or more of the following conditions:
- Previous amputation of the other foot, or part of either foot, or
- History of previous foot ulceration of either foot, or
- History of pre-ulcerative calluses of either foot, or
- Peripheral neuropathy with evidence of callus formation of either foot, or
- Foot deformity of either foot, or
- Poor circulation in either foot
The patient has a prescription for a particular type of footwear from a podiatrist or physician who is knowledgeable in the fitting of diabetic shoes and inserts.
A “Statement of Certifying Physician for Therapeutic Shoes” from a physician who manages the patient’s diabetes, which certifies that the patient has diabetes mellitus, has at least one of the qualifying conditions , is being treated under a comprehensive plan of care for his or her diabetes, and needs diabetic shoes.
Does Medicare Cover Orthotic Shoes Or Inserts
Orthotic shoes are custom-fitted footwear designed to reduce the patients pain for a variety of health conditions including:
Metatarsalgia: chronic pain in the ball of the foot
Plantar fasciitis: chronic breakdown of soft tissue around the heel
Bunions: a painful, bony bump on the outside of the big toe
For the most part, Medicare does not cover orthopedic or inserts or shoes, however, Medicare will make exceptions for certain diabetic patients because of the poor circulation or neuropathy that goes with diabetes.
Medicare may cover the fit and cost of one pair of custom-fitted orthopedic shoes and inserts once per year for those patients.
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Qualifications For Reimbursement For Orthopedic Shoes & Inserts
- Partial or complete foot amputation
- Past foot ulcers
- Nerve damage in your feet with signs of calluses on either foot
- Deformity of either foot
- Poor circulation in either foot
- You meet the criteria for the shoes
- The doctor is treating you under a comprehensive plan of care for diabetes
- The exact reasons you need the therapeutic shoes and/or inserts
If you meet all the aforementioned conditions there are still other factors that may affect the amount of your reimbursement. Make sure you check with your doctor and plan provider.
Medicare Coverage Of Podiatry Exams
Patients with diabetes, diabetic neuropathy or loss of sensation in the foot are eligible to have one diabetic foot examination covered every six months. This falls under Medicare Part B and there are conditions. Recipients of coverage cannot have been treated by a podiatrist for another type of foot problem during that six month interval, for instance.
Those attending Medicare-assigned podiatrists are typically on the hook for 20 percent of any permissible charge plus the Medicare Part B deductible. Those seeing specialists in outpatient facilities are responsible for copayments. And those with foot deformities or other injuries are entitled to up to 80 percent of allowable charges, with the patient lined up to pay the remaining 20 percent and any deductible.
Original Medicare, which includes Part A and Part B, does not cover whats known as routine podiatry services, however.
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Orthotic Shoes Or Orthopedic Shoes
Special shoes for certain unusual or abnormal foot conditions, to improve comfort and function. They are created mostly for recreational use and for pathologic foot conditions. This definition includes high-quarter shoes, or chukka boots, which cover the medial malleoli.
Reese Orthopedic Shoe is a canvas and wooden sole shoe used post-operatively to reduce motion in joints of the foot. This shoe is also known as a Darby Shoe.
Clawson Rocker Shoes serve as a walking aid for patients with multiple sclerosis.
Straight Last Shoes serve as a corrective splint for metatarsus adductus.
Does Medicare Pay For Orthotic Inserts
Medicare pays for orthotic shoes and inserts if you have severe foot disease or diabetes, and your doctor orders them. In many cases, Medicares durable medical equipment program covers equipment you use at home. While custom shoes and inserts are covered by Medicare Part B, they are not considered DME.
If your doctor orders custom orthotic shoes or inserts for an approved condition, your Medicare Part B plan will cover the following each year:
- One pair of custom-molded shoes
- One pair of custom-molded inserts
- One pair of extra-depth shoes
- Two pairs of additional inserts for custom-molded shoes
- Three pairs of additional inserts for extra-depth shoes
- Modifications for custom shoes instead of inserts
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Do You Have More Questions About Medicare Coverage
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Does Medicare Cover Orthotics After Hip Replacement Surgery
Sometimes doctors prescribe hip braces as a part of hip replacement surgery recovery. However, hip braces oftentimes dont include a foot orthotic device. Medicare may help pay for the hip brace as part of your DME coverage, but coverage may not include an orthotic device.
According to Dr. James P. Ioli, DPM, a podiatrist with the Harvard Medical School, you should have a physical therapist assess your pelvic, hip, knee, ankle, and foot movement to examine how your soft tissue restrictions and flexibility contributes to your pain. The physical therapist can address your pain and make recommendations to manage it.
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Does Medicare Cover Routine Foot Care
Medicare does not cover routine foot care because those services are rarely considered medically necessary. Routine treatments include nail care, hygienic services and treatment of corns and calluses. Routine care can be beneficial to your health, but it is typically considered to be preventive.
However, there are some conditions that might make routine foot care a medically necessary service, which then qualifies you for coverage. These conditions include alcoholism, pernicious anemia, Buergers disease and other ailments that can severely affect your feet. Most diseases that affect the metabolic, neurologic or vascular systems could also make routine foot care medically necessary.
Check with your doctor or health care provider if you think you have a condition that might impact your feet enough to deem routine care medically necessary.
How Much Do Diabetic Shoes Cost
Diabetic shoes can be costly because theyre specialty shoes and need to be custom-fitted for your feet. On average, diabetic shoes can range in cost from $50-$200 per pair.
Your out-of-pocket costs may depend on several factors:
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Does Medicare Cover Orthotics For Weight Loss
According to the Hospital for Special Surgery , orthotics can help ease the extra stress on the feet for overweight people. Medicare does not cover orthotics for people who are overweight just because they are overweight.
You may also be able to get over-the-counter benefits with some Medicare Advantage plans. So, even though you may not qualify for prescription orthotic coverage, you may be able to find coverage for over-the-counter products you can find at your local drugstore or mail-order pharmacy.
Original Medicare Coverage For Various Types Of Orthotics
People often think of orthotics as custom-made shoe inserts that can relieve foot pain. Thats a popular type of orthotic, but there are other types as well, such as back braces. Medicare counts them as durable medical equipment. Medicare Part B may cover orthotics if both of the following are true:
- Your Medicare doctor prescribes orthotics for you as medically necessary.
- You buy the orthotics from a Medicare-participating supplier.
Medicare Part B may also cover therapeutic shoes and inserts for people with diabetes who suffer from severe diabetic foot disease, if your Medicare-assigned doctor certifies that you need them. As with orthotics, these items must come from a Medicare-participating supplier.
Medicare classifies orthotics under the Durable Medical Equipment Prosthetics, Orthotics, & Supplies category. If you meet the conditions described above, Original Medicare generally pays 80 percent of the Medicare-approved cost for orthotics, therapeutic shoes, and shoe inserts after you have met your deductible after that, youll only be responsible for the remaining 20 percent. You might want to take a look at this article on planning your Medicare health costs for retirement.
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Therapeutic Shoes As Integral Parts Of A Leg Brace
Note: Even under plans that exclude coverage of foot orthotics, Aetna covers therapeutic shoes if they are an integral part of a covered leg brace and are medically necessary for the proper functioning of the brace. Oxford shoes are usually covered in these situations. Other shoes, e.g., high-top, depth inlay or custom-molded for non-diabetic, etc., may also be covered if they are an integral part of a covered leg brace. Medically necessary heel replacements, sole replacements, and shoe transfers are also covered for therapeutic shoes that are an integral part of a covered leg brace. Inserts and other shoe modifications of shoes that are an integral part of a leg brace are covered if they are medically necessary for the proper functioning of the brace. Medically necessary shoe and related modifications, inserts, and heel/sole replacements, are covered when the shoe is an integral part of a leg brace. A matching shoe, which is not attached to the brace and items related to that shoe, are also covered.
Shoes that are billed separately will not be covered even if they are later incorporated into a brace.