Therapeutic Shoes vs Orthopedic Footwear - JA DME

Medicare has limited coverage provisions for shoes, inserts, and shoe modifications used by beneficiaries. In order to be eligible for coverage, such items must qualify in either:

1. The benefit category for therapeutic shoes provisioned in the treatment of a diabetes-related condition(s); or
2. The benefit category for leg braces (to which the shoes and related items would be considered for coverage as integral components of the leg brace).

Orthopedic shoes are covered if they are an integral part of covered leg brace:

• Search applicable brace codes in Orthopedic Footwear Policy Article A52481
• When initially providing a brace, the shoes incorporated into that brace must be billed by same supplier
• Shoes billed separately (i.e., not as part of brace) deny as noncovered

Shoes/related modifications, inserts, heel/sole replacements, shoe transfers:

• Only covered when shoe is integral part of covered leg brace
• Must be medically necessary for proper functioning of brace
• Must be billed with KX modifier or will deny noncovered, statutorily excluded

Shoe transfers to beneficiary-owned item:

• All suppliers are allowed to provide replacement shoes or braces when the shoe is an integral part of a covered leg brace. When billing the transfer, follow the Orthopedic Footwear Policy Article.
• KX modifier must be added to the code.
• An order is not required for the transfer of a shoe to a brace.