Therapeutic footwear is used to prevent diabetic ulcers. Orthopedic footwear is used by people with structural conditions of the foot.
Therapeutic shoes, modifications and inserts must be prescribed by a podiatrist or physician knowledgeable in the fitting of diabetic shoes and inserts.
Orthopedic shoes, modifications and inserts must be prescribed by a podiatrist or physician knowledgeable in the fitting of orthopedic shoes and inserts.
All shoes, modifications and inserts must be fitted and furnished by a qualified individual such as a podiatrist, pedorthist, orthotist or prosthetist.
Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare in order to assist recipients for whom MHCP is not the primary payer.
MHCP quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested.
Orthotics are covered for all eligible MHCP members.
Codes: A5500-A5501 (therapeutic shoes), A5503-A5507 (modifications to therapeutic shoes), A5510-A5513, K0903 (inserts for therapeutic shoes)
Custom-made or stock therapeutic shoes and modifications to therapeutic shoes are covered for MHCP members with diagnosed diabetes and one or more of the following conditions:
Inserts for therapeutic shoes, whether custom-made or stock, are covered only when the member has covered therapeutic shoes.
Two pairs of therapeutic shoes, three pairs of inserts (A5512, A5513, K0903), and two pairs of inserts (A5510) are covered without authorization in a calendar year. They can be dispensed at the same time, or at different times.
MHCP uses the coding guidelines for therapeutic shoes, modifications and inserts that are found in the Medicare Local Coverage Article for Therapeutic Shoes for Persons with Diabetes for Medicare’s DME MAC contractor for the state of Minnesota.
Codes: L3000-L3031 (custom inserts), L3040-L3060 (premolded, removable arch supports), L3070-L3100 (nonremovable arch supports), L3140-L3150 (abduction and rotation bars), L3224-L3253 (orthopedic footwear), L3300 – L3595 (additions and modifications to orthopedic shoes), L3600-L3640 (transfer of orthotic), L3649
MHCP will cover custom-made orthopedic shoes, modifications (including additions) and inserts when the shoe is an integral part of a leg brace, or for recipients with one or more of the following medical conditions:
MHCP will cover stock orthopedic shoes only if the shoes are an integral part of a covered leg brace and if they are medically necessary for the proper functioning of the leg brace.
MHCP will cover stock inserts only for use in covered orthopedic shoes.
Two pairs of orthopedic shoes and two pairs of inserts are covered without authorization in a calendar year.
A foot pressure off-loading device is covered for pressure reduction for existing pressure ulcers on the foot.
MHCP does not cover the following:
Authorization for orthopedic footwear is required only when a third pair or subsequent pair of orthopedic shoes or a third pair or subsequent pair of inserts is required in any calendar year. Authorization will be granted when the items are needed because of a change in the member’s medical condition or size which requires replacement.
Authorization for therapeutic footwear is required only when a third pair or subsequent pair of therapeutic shoes, a third pair or subsequent pair of inserts under code A5510, or a fourth pair of inserts (A5512, A5513, K0903) is required in any calendar year. Authorization will be granted when the items are needed because of a change in the member’s medical condition or size which requires replacement.
Submit authorization requests through MN–ITS (Authorization Request 278). Fax the MN–ITS response with the required documentation, physician’s orders and appropriate additional information to the medical review agent. Write the MN–ITS Authorization Request number on each page of each document. Document the reason the shoes or inserts require replacement.
Affiliate: A person that directly or indirectly, through one or more intermediaries, controls or is controlled by, or is under common control with, the referring physician or consultant.
Custom-made: Made for a specific patient from his or her individual measurements or pattern
Inserts: Artificial devices that are placed in a shoe to assist in restoring or maintaining normal alignment of the foot
Physiatrist: A physician who specializes in physical medicine or who possesses specialized knowledge of rehabilitation and who is certified by the American Board of Physical Medicine and Rehabilitation.
Prosthetic: An artificial device, as defined by Medicare, to replace a missing or nonfunctional body part
Stock: Off the shelf items that are not fabricated to an individual’s specifications. They may be adjusted or altered to meet the person’s needs, but are not made specifically for the person.Report/Rate this page