Shoes for Diabetics Mandate
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Documents the Rhode Island state-mandated coverage for therapeutic/molded shoes and inserts for people with diabetes under Commercial Products; describes coverage, required coding, and applicability to benefit booklets.
No material clinical or coverage changes in this revision.
Coverage criteria for therapeutic shoes and inserts
State-mandated coverage (Commercial Products)
Covered when ALL of the following are met:
Applies to insulin-treated, non-insulin-treated, and gestational diabetes when medically appropriate; benefits vary by contract. Refer to the member's Benefit Booklet/Evidence of Coverage for applicable benefits.
This policy documents the Rhode Island state-mandated coverage for therapeutic shoes and inserts for people with diabetes and applies to Commercial Products only. Coverage is provided when the requirements of RIGL § 27-20-30 are met and the shoes/inserts are medically appropriate and prescribed by a physician. For Medicare Advantage members, this document does not govern benefits; those members’ coverage follows CMS guidelines and the applicable Evidence of Coverage or Benefit Booklet.
This policy does not enumerate any situations or services that are explicitly listed as not medically necessary. The document states the coverage stance and conditions for commercial products but does not provide a separate list of exclusions labeled as not medically necessary.
HCPCS codes and product specifications
| 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. |
| A5508 | For diabetics only, deluxe feature of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe. |
| A5510 | For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple-density insert(s) prefabricated, per shoe. |
| A5512 | For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient's foot, including arch, base layer. |
Provider actions, authorization, and benefit guidance
No prior authorization required
Prior authorization review is not required for therapeutic shoes for diabetics under this policy for Commercial Products.
No medical criteria or step therapy
This policy does not impose any medical criteria or step therapy requirements for therapeutic shoes for diabetics.
Medical prescription and special fitting required
Therapeutic/molded or depth shoes and inserts must be medically appropriate and prescribed by a physician in accordance with RIGL 27-20-30; the shoes are specially fitted and, where applicable, may be custom-molded or depth shoes with removable inserts.
- RIGL 27-20-30 requires coverage when medically appropriate and prescribed by a physician (see statute language).
- Definition: Custom molded shoes are constructed over a positive model of the patient's foot with removable inserts.
- Definition: Depth shoes provide a minimum of 3/16" additional depth to accommodate inserts; inserts are total-contact, multi-density removable inlays.
Verify benefits; risk of denial for contract mismatch
Coverage and benefits vary by group/contract; services that are inconsistent with the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement may be denied or not covered.
- Confirm member is on a Commercial product governed by Rhode Island law and verify applicable Benefit Booklet/Evidence of Coverage before providing or billing services.
Background on therapeutic shoes and inserts
Therapeutic or molded shoes and removable inserts are intended to protect feet with decreased sensation and to support feet that have changed shape, helping to prevent complications such as ulceration and amputation. Custom molded shoes are constructed over a positive model of the patient’s foot and include removable inserts. Depth shoes provide additional depth to accommodate inserts. Inserts are total-contact, multi-density, removable inlays that redistribute pressure and provide cushioning and support.
Definitions of shoe and insert types
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