CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Therapeutic Shoes for Diabetics Mandate

Documents Rhode Island state-mandated coverage requirements for therapeutic/molded shoes and inserts for commercial Blue Cross Blue Shield - Rhode Island members; BlueCHiP for Medicare is governed by CMS and not by this state mandate. Applicable to commercial products and benefits may vary by contract.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyTherapeutic Shoes for Diabetics Mandate

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 7, 2007

Next Review DateN/A

Key ActionPrescribe therapeutic shoes when medically appropriate and document medical necessity per RIGL 27-20-30.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CommercialApplies to plan type

No prior authAuthorization requirement

A5500–A5513, K0903Covered HCPCS codes

RIGL 27-20-30Governing state statute

State-Mandated Coverage Criteria

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State-mandated coverage criteria

Covered when ALL of the following are met:

Mandate requirements

Product types: Includes molded shoes, depth shoes, and multiple-density removable inserts; custom molded shoes and specified modifications and features are described and covered via the listed HCPCS codes (A5500–A5507, A5508, A5510, A5512, A5513, K0903).

Clinical indication: Member has diabetes (insulin-treated, non–insulin-treated, or gestational) and the therapeutic shoes/inserts are medically appropriate to prevent amputation or to protect feet with decreased sensation or altered foot shape.

Medical appropriateness must be documented and the items prescribed by a physician per RIGL 27-20-30.

This policy implements the Rhode Island statutory mandate (RIGL 27-20-30) for coverage of therapeutic/molded shoes and multiple-density removable inserts when medically appropriate and prescribed by a physician. The mandate and resulting coverage apply to Blue Cross Blue Shield — Rhode Island commercial products; BlueCHiP for Medicare is governed by CMS and the state mandate does not apply to those Medicare plans. Benefit specifics (including copayments, deductibles, and exact coverage rules) may vary by group or contract and providers should confirm member-specific benefits in the member's Benefit Booklet or Evidence of Coverage.

Services determined to be not medically necessary or services that are non-covered benefits under a member's contract are excluded from coverage under this policy. If non-covered or not medically necessary services are provided, a member should not be billed unless they were informed and provided written consent to pay for the services in advance; benefit determinations are controlled by the member's subscriber agreement, employer agreement, or Evidence of Coverage.

HCPCS Coding

Covered HCPCS Codes (group 1)HCPCSCovered

A5500	For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe.
A5501	For diabetics only, fitting (including follow-up), custom preparation and supply of shoe molded from cast(s) of patient's foot (custom-molded shoe), per shoe.
A5503	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with roller or rigid rocker bottom, per shoe.
A5504	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with wedge(s), per shoe.
A5505	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with metatarsal bar, per shoe.
A5506	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with off-set heel(s), per shoe.
A5507	For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe.

Provider Requirements and Billing Notes

Prior Authorization

Prior Authorization — Not Required

Prior authorization review is not required for commercial products.

Note

Benefit Variability by Contract

Benefits vary by group contract. Refer to the member's Benefit Booklet, Evidence of Coverage, Subscriber Agreement, or employer agreement for applicable coverage, limitations, copayments, and deductible information for diabetic equipment/supplies, medical equipment, medical supplies, and prosthetic devices.

Documentation Required

Medical Necessity and Prescription Requirement

Coverage for therapeutic/molded shoes and related diabetic supplies is mandated by Rhode Island law when medically appropriate and prescribed by a physician. Services and items must be medically necessary and, when required by contract, prescribed by a physician to be covered. If services are determined not to be medically necessary or are non-covered benefits, the provider may not bill the member unless the member was informed and provided written agreement to pay out-of-pocket in advance.

Therapeutic shoes (molded or depth) and inserts are covered when medically appropriate and prescribed.
Coverage includes blood glucose monitors, test strips, insulin, syringes, pumps, and related supplies per RIGL 27-20-30(a).

Denial Risk

Denial Risk for Non‑Covered or Not Medically Necessary Services

Services that are not covered by the member's contract or that are not medically necessary may be denied. Verify member-specific benefits and eligibility with the provider call center and the member's subscriber documents prior to providing equipment or services.

Potential denials include items not prescribed by a physician or determined not medically necessary.
Providers should obtain prior member benefit verification to avoid unexpected denials or member liability.

Clinical Background

Therapeutic and custom-molded shoes and multiple-density removable inserts are intended to protect feet with decreased sensation and to accommodate feet that have changed shape, reducing the risk of ulcers and amputation in patients with diabetes. Covered product types include custom-molded shoes (constructed over a positive model of the patient's foot with removable inserts), depth shoes (providing additional depth to accommodate inserts), and multiple-density, total-contact inserts (removable inlays molded to the patient's foot or a model). Specific covered modifications and features are described and billed using the listed HCPCS codes.

Definitions

Custom molded shoes definition

MaterialsMade of leather or other suitable material of equal quality.

FeaturesHave some form of shoe closure.

PurposeSpecially fitted to provide protection for feet with decreased sensation and to support feet that are changing in shape when normal shoes are inadequate.

Depth shoe definition

DefinitionA depth shoe has a full-length, heel-to-toe filler that, when removed, provides a minimum of 3/16" of additional depth to accommodate custom molded or customized inserts.