One pair of Depth
Shoes.
3 pair of inserts.
Diabetic shoes,
inserts and/or modifications are covered if the following criteria
are met:
1) Patients who have diabetes mellitus (ICD-9-CM diagnosis code 250.00-250.91)
and:
2) This patient has one or more of the following conditions:
a. History of partial or complete amputation of the foot.
b. History of previous foot ulceration.
c. History of pre-ulcerative callus.
d. Peripheral Neuropathy with evidence of callus formation.
e. Foot deformity.
f. Poor circulation.
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. The certifying physician must be an M.D. or D.O.
This policy requires
that the certifying physician, providing the medical care for the
diabetic condition must sign a statement that the conditions stated
above are met.
The prescribing
physician may be a podiatrist, M.D. or D.O. and should write the order
for the therapeutic shoes, modifications, and inserts.
The supplier,
the person or entity furnishing the shoes, modifications, or inserts
may be a podiatrist, pedorthist, orthotist, prosthetist, or other
qualified individual. The supplier should bill Medicare for the service.