Coverage

• Therapeutic Shoes for Persons with Diabetes Local Coverage Determination (LCD) and Policy Article [PDF]

Documentation

Document Type	Description
Documentation Checklist [PDF]	Suppliers may use this checklist to ensure all of the required documentation is gathered
Physician Letter – Documentation Requirements [PDF]	Suppliers may use this letter written by the DME Medical Directors to assist in requesting required documentation from physicians.
Physician Letter – Medical Records [PDF]	Suppliers may use this letter written by the DME Medical Directors to assist in obtaining medical records from physicians.
Statement of Certifying Physician for Therapeutic Shoes	This is the recommended form to use to meet the documentation requirements stating "The supplier must obtain a signed statement from the physician who is managing the patient's systemic diabetes condition (i.e., the certifying physician) specifying that the patient has diabetes mellitus, has one of conditions 2a-2f listed in the related Policy Article, is being treated under a comprehensive plan of care for his/her diabetes, and needs diabetic shoes."

 

Reviews/Audits

Review Type	Description
Medical Review	View notifications and findings of pre and post claim reviews completed by Noridian Medical Review Staff

 

Resources

Topic	Brief Description
Clarification of Criterion 5	Per the LCD, "The in-person evaluation of the beneficiary by the supplier at the time of delivery…must be conducted with the beneficiary wearing the shoes and inserts and must document that the shoes/inserts/modifications fit properly."
Toe Fillers and Diabetic Shoe Inserts	Shoe inserts for beneficiaries with missing toes or partial foot amputations who are not diabetic are considered for coverage under the prosthetic benefit