Currentblue cross blue shield - michiganPolicy N/A

Orthopedic shoes and orthotic shoe inserts — Medicare Plus Blue enhanced benefit

Defines Medicare Plus Blue (Medicare Advantage) coverage, payment, frequency limits, and member cost sharing for orthopedic shoes and orthotic shoe inserts for eligible Medicare Plus Blue members.

Policy Summary

Payerblue cross blue shield - michigan

PolicyOrthopedic shoes and orthotic shoe inserts — Medicare Plus Blue enhanced benefit

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionVerify benefits and cost-share via provider portal or phone prior to furnishing items and seek a coverage determination if coverage is uncertain.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100%coverage up to approved amount for this enhanced benefit

Part B ded. + 20%member cost sharing collected by providers

L3000-L3649listed payable HCPCS code ranges

Variesfrequency limitations across code groups

Medicare Plus Blue Coverage & Payment Rules

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Medicare Plus Blue coverage criteria and payment rules

Coverage follows Original Medicare baseline with specified enhancements and payment rules for Medicare Plus Blue members.

ALL of the following

ONE of
- One pair of custom-molded shoes and inserts is covered each calendar year for members with diabetes and severe diabetic foot disease.1 per calendar year
  Medicare Part B baseline coverage applies.
- One pair of extra-depth shoes is covered each calendar year for members with diabetes and severe diabetic foot disease.1 per calendar year
  Medicare Part B baseline coverage applies.

ALL of the following

AS APPLICABLE
- Two additional pairs of inserts each calendar year for custom-molded shoes.2 per calendar year
- Three additional pairs of inserts each calendar year for extra-depth shoes.3 per calendar year

ALL of the following

Orthopedic shoes are covered when they are part of a leg brace; heel replacements and shoe transfers involving shoes on a covered brace are covered.
Inserts and shoe modifications integral to a covered brace are covered if medically necessary for brace functioning.
Items billed without a required KX modifier will be denied as noncovered when statutorily excluded under Medicare rules.
Follow Medicare billing modifier requirements.
Enhanced benefit note: The Medicare Plus Blue enhanced benefit may cover orthopedic shoes even when not attached to a leg brace (noting Original Medicare requires brace attachment).

ALL of the following

Frequency limits apply by HCPCS code as specified in policy; providers must adhere to those limits for payment consideration.
Examples: 2 every 3 years for L3030-L3031/L3020/L3000/L3010; 1 every year for L3254/L3255/L3257/L3260/L3265; 1 every 3 years for L3100/L3140/L3150; 3 every 6 months for L3300-L3334; 2 every 1 year for L3001-L3003, L3040-L3090, L3215-L3230, L3250-L3253; 2 every 6 months for L3160/L3170/L3201-L3204/L3206-L3209.

ALL of the following

Provider payment is the lesser of Medicare's allowed amount or the provider's charge, minus the member's cost share.
This represents payment in full and providers may not balance bill the member.
Providers should collect the applicable Part B deductible and 20% coinsurance from members as the Medicare Plus Blue cost share.
Providers can only collect the appropriate Medicare Plus Blue cost sharing amounts.

ALL of the following

If a member elects a noncovered service, the member is responsible for the entire charge for that noncovered service.
Providers may not have members sign ABN to accept financial responsibility for noncovered items; if coverage is uncertain, obtain a coverage determination before furnishing the item.
If a provider issues a noncovered item without first obtaining a coverage determination, the member must be held harmless for all charges except any applicable cost share.

ALL of the following

Verify benefits and cost-share via the provider portal or by calling the provided phone number prior to furnishing items.
Provider portal or phone: 1-866-309-1719.

Applicable HCPCS Codes & Frequency Limits

Applicable HCPCS code rangesHCPCSCovered

L3000-L3031	Foot Inserts, Removable.
L3040-L3080	Foot Arch Supports.
L3100-L3170	Repositioning Foot Orthotics.
L3201-L3207	Orthopedic Shoes.
L3208-L3211	Surgical Boots.
L3212-L3214	Benesch Boots.
L3215-L3265	Other Orthopedic Footwear.
L3300-L3334	Shoe Lifts.
L3340-L3420	Shoe Wedges.
L3430-L3485	Shoe Heels.

1–10 of 12

1/2

Frequency limits by code group

Example: 2 every 3 yearsHCPCS codes L3030, L3031, L3020, L3000, L3010 — payable up to 2 pairs every 3 years.

Example: 1 every yearHCPCS codes L3254, L3255, L3257, L3260, L3265 — payable once every calendar year.

Example: 1 every 3 yearsHCPCS codes L3100, L3140, L3150 — payable once every 3 years.

Example: 3 every 6 monthsHCPCS codes L3300, L3310, L3320, L3334 — payable up to 3 every 6 months.

Example: 2 every 1 yearHCPCS codes L3001-L3003, L3040-L3090, L3215-L3217, L3219, L3221-L3222, L3224-L3225, L3230, L3250-L3253 — payable up to 2 per year.

Example: 2 every 6 monthsHCPCS codes L3160, L3170, L3201-L3204, L3206-L3209 — payable up to 2 every 6 months.

Benefits Verification & Pre-Service Determinations

Prior Authorization

Verify benefits and obtain pre-service coverage determination

Verify member benefits and the applicable Part B deductible and 20% coinsurance through the Medicare Plus Blue provider portal or by calling 1-866-309-1719 before furnishing orthopedic shoes or orthotic shoe inserts. If coverage is uncertain, obtain a coverage determination from Medicare Plus Blue prior to providing the item.

Providers may only collect the appropriate Medicare Plus Blue cost sharing amounts from the member.
If there is any question about whether an item is covered, seek a coverage determination from Medicare Plus Blue before providing the item.
If a provider issues a noncovered item without first obtaining a coverage determination, the member must be held harmless for all charges except any applicable cost share.

Device Definitions and Orthotics Categorization

Orthopedic shoes and orthotic shoe inserts

DefinitionDevices intended to correct an abnormal or irregular walking pattern by slightly altering the angles at which the foot strikes a surface.

Medicare Part B annual coverage (diabetes + severe diabetic foot disease)Covers furnishing and fitting of either orthopedic shoes or orthotic shoe inserts each calendar year: one pair of custom-molded shoes and inserts or one pair of extra-depth shoes.

Intended useTo modify foot strike and gait mechanics to address diabetic foot disease and related functional needs.

Orthotics (Medicare DME categorization)

Medicare DME orthotics — included devicesBracing for ankle, foot, knee, back, neck, spine, hand, wrist, elbow; orthopedic shoes as part of a leg brace; prosthetic devices (artificial limbs).

Orthopedic shoes as brace componentOrthopedic shoes are covered by Medicare only when they are a necessary part of a leg brace; heel replacements and shoe transfers for covered braces are also covered.

Coverage for inserts/modifications with bracesInserts and other shoe modifications are covered if they are on a shoe that is an integral part of a covered brace and are medically necessary for proper functioning of the brace.