Medicare Footwear Benefit for Patients with Diabetes
Your patients may be able to benefit from a Medicare Part B health benefit known as the “Therapeutic Shoes for Individuals with Diabetes Bill” and more commonly referred to as the “Diabetic Shoe Bill.” The benefit is scrupulously regulated and enforced, but for qualifying patients, it can help reduce the risk of ulceration and amputation.
The Bill was enacted by Congress in 1993 following demonstration projects in several markets between 1987 and 1993 and a subsequent study that showed that “a Medicare therapeutic shoe benefit would be cost-neutral to the Medicare program.” The current legislation provides that Medicare will pay 80% of the allowable costs of a pair of depth shoes (or custom-molded shoes) and shoe inserts or modifications every calendar year to qualifying Medicare Part B beneficiaries with diabetes (a Medicare beneficiary’s supplemental insurance usually pays for the remaining 20% of the allowable costs). Qualifying shoes with extra depth enable the feet to move about more freely without any pressures being placed on them and provide room for the placement of any inserts that could further protect them. The idea is that the shoes and inserts function together to minimize the formation of lesions and foot ulcers that could go on to become infected, ultimately gangrenous, and then require amputation. IPFH recommends fitting the shoes and inserts together with padded socks (for further protection) at the same time, so that all three components—shoes, inserts, padded socks—work together as a system. IPFH calls this the “integrated approach” and recommends this approach when patients receive or purchase any new pair of shoes.
Patients qualify for the benefit if they are Medicare Part B beneficiaries with diabetes mellitus (ICD-9 codes: 250.00-250.93) and if they are diagnosed with one or more of the following additional conditions:
- previous amputation of the foot, or part of either foot
- history of previous foot ulceration of either foot
- history of pre-ulcerative calluses of either foot
- peripheral neuropathy with evidence of callus formation of either foot
- foot deformity of either foot
- poor circulation in either foot
Fulfuillment of the benefit is typically provided by a durable medical equipment (DME) supplier.
To reduce fraud and abuse in the diabetic footwear program, the Center for Medicare and Medicaid Services requires a Certifying Physician’s Statement (from the MD or DO who is managing the beneficiary’s diabetes), which must be maintained in the DME supplier's files and must be dated prior to the dispensing of shoes/inserts. The Certifying Physician’s Statement must affirmatively state or specify that:
- the patient has diabetes and one or more of the required additional conditions listed above;
- he or she is treating the beneficiary under a comprehensive plan of care for his or her diabetes; and
- the beneficiary is actually in need of therapeutic shoes, inserts and/or modifications.
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