CurrentCapital BluecrossPolicy MP 6.061

Therapeutic shoes for persons with diabetes

Defines medical necessity, coding, and coverage conditions for therapeutic/custom diabetic shoes, inserts, and modifications for members with diabetes under Capital Blue Cross programs (subject to member contract variations and state/federal mandates). Applies to eligible providers prescribing orthotics.

Policy Summary

PayerCapital Bluecross

PolicyTherapeutic shoes for persons with diabetes

Policy CodePolicy MP 6.061

Change TypeCoding and administrative updates

Effective Date12/1/2025

Next Review Date

Key ActionDocument diabetes diagnosis plus at least one qualifying foot condition when ordering therapeutic shoes, inserts, or modifications.

SourceLink

POLICY UPDATE CHANGES

Updated all NMN statements to INV (investigational) and updated references; coding reviewed, no changes.

Removed Benefit Variations and updated the Disclaimer (administrative update).

Added ICD-10 code E11.A to coding list.

MP 6.061policy identifier

12/1/2025effective date

A5508, A5510investigational codes

A5500-A5514covered procedure codes

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E08-E13; E11.Adiagnosis codes

Medical Necessity and Coverage Criteria

Initial eligibility for therapeutic shoes/inserts/modifications

Covered when ALL of the following are met

Primary requirements

Qualifying foot conditions
- Previous amputation of the other foot or part of either foot
- History of previous foot ulceration of either foot
- History of pre-ulcerative calluses of either foot
- Peripheral neuropathy with evidence of callus formation of either foot
- Foot deformity of either foot
- Poor circulation in either foot

Provider requirement: An eligible provider must prescribe the orthotics and be involved in the member's care

See provider documentation requirements

Replacement / Modification criteria

Replacement criteria for existing customized shoes/inserts

Replacement justification: Replacement or modification is medically necessary when due to wear out, loss of effectiveness, change in foot size/shape, change in foot structure, or development of new skin breakdown, ulceration, or deformity; not for convenience or style change.

Replacements follow same medical necessity criteria as original item

Deluxe shoe features (for example, style, color, or type of leather) do not contribute to the therapeutic function of the shoe and are considered investigational due to insufficient evidence of clinical benefit. Items represented by HCPCS code A5510 are described in the policy as reflecting compression molding to the individual’s foot over time (heat and pressure generated by wearing a shoe with the insert present); because these inserts are not total contact at dispensing they are considered investigational and do not meet medical necessity criteria.

When the documented medical necessity criteria are not met (see required diabetes diagnosis plus one or more qualifying foot conditions), requests for diabetic shoes and custom inserts will be denied as investigational due to insufficient evidence to support health outcomes. The policy explicitly lists HCPCS codes A5508 and A5510 under not medically necessary / investigational procedure codes and these may trigger denial when criteria are unmet.

Procedure and Diagnosis Codes

Not Medically Necessary / Investigational Procedure CodesHCPCSNot Covered

A5508	Procedure code listed under Not Medically Necessary / Investigational
A5510	Procedure code listed under Not Medically Necessary / Investigational

Medically Necessary Procedure CodesHCPCSCovered

A5500	Listed as covered / medically necessary for diabetic orthotic
A5501	Listed as covered / medically necessary for diabetic orthotic
A5503	Listed as covered / medically necessary for diabetic orthotic
A5504	Listed as covered / medically necessary for diabetic orthotic
A5505	Listed as covered / medically necessary for diabetic orthotic
A5506	Listed as covered / medically necessary for diabetic orthotic
A5507	Listed as covered / medically necessary for diabetic orthotic
A5512	Listed as covered / medically necessary for diabetic orthotic
A5513	Listed as covered / medically necessary for diabetic orthotic
A5514	Listed as covered / medically necessary for diabetic orthotic

Diagnosis CodesICD-10

E08-E13	Diabetes diagnosis range listed as covered for medically necessary diabetic orthotic
E11.A	Specific ICD-10 code added to policy
O21.011-O24.93	Pregnancy/diabetes related diagnosis range listed

Provider Responsibilities, Documentation, and Billing Guidance

Denial Risk

Medical necessity prerequisite

Diabetic shoes, inserts, and modifications are medically necessary only when the patient has a diagnosis of diabetes mellitus AND one or more qualifying foot conditions (previous amputation, history of foot ulceration, pre‑ulcerative calluses, peripheral neuropathy with callus formation, foot deformity, or poor circulation). Replacements or modifications must be justified by clinical need (e.g., worn out, loss of effectiveness, change in foot size/shape or structure, new skin breakdown/ulceration or deformity). Items not meeting these medical necessity criteria will be denied as investigational.

Replacement/modification justification: worn out, loss of effectiveness, change in foot size/shape, change in foot structure, or development of new skin breakdown, ulceration, or deformity

Step Therapy

Step therapy

There are no step therapy requirements specified for therapeutic shoes, inserts, or modifications in this policy.

Key Definitions

Inserts — definition and characteristics

DefinitionInserts are total contact, multiple-density, removable inlays directly molded to the member's foot or a model of the member's foot.

Material requirementMade of a material suitable for the member's condition.

Construction characteristicsMultiple densities to provide differential cushioning and pressure redistribution.

Form factorRemovable inlay that can be fitted inside therapeutic or custom shoes.

Manufacture basisDirect molding to the member's foot or use of a model of the member's foot to achieve total contact.

Rigid rocker/roller bottoms — technical details

Background and Scope

Therapeutic shoes are specially designed footwear intended to address complications of diabetes by reducing pressure on the foot and preventing skin breakdown, ulceration, and amputation. The policy covers both custom-molded (total contact) and depth-inlay therapeutic shoes when medical necessity is documented. Coverage is contingent on a diagnosis of diabetes mellitus plus one or more qualifying foot conditions (for example prior amputation, prior ulceration, pre‑ulcerative callus, peripheral neuropathy with callus formation, foot deformity, or poor circulation). Replacements or modifications of custom shoes follow the same medical necessity criteria and must be justified by need (e.g., worn out, loss of effectiveness, change in foot size/shape, new skin breakdown, ulceration, or deformity), not for convenience or style.

Policy Changes and History

2025-09-02administrative_updateLatest

Added ICD-10 code E11.A to the coding list.

2025-06-09administrative_update

Removed Benefit Variations and updated the Disclaimer (administrative update).

2024-12-23consensus_review

Policy Summary

PayerCapital Bluecross

PolicyTherapeutic shoes for persons with diabetes

Policy CodePolicy MP 6.061

Change TypeCoding and administrative updates

Effective Date12/1/2025

Next Review Date

Key ActionDocument diabetes diagnosis plus at least one qualifying foot condition when ordering therapeutic shoes, inserts, or modifications.

SourceLink

On This Page

Documentation Required

Provider relationship and documentation

The provider requesting or ordering the DME/orthotic must be a provider with whom the member has an established relationship and who is involved in the ongoing care of the member and the condition for which the device is prescribed. Documentation submitted with claims or prior authorization requests must support the diabetes diagnosis, the qualifying foot condition(s), and the clinical rationale for any replacement or modification (including timing and reason).

Provider must be eligible and involved in ongoing care
Documentation must document diabetes diagnosis, qualifying foot condition(s), and justification for replacement/modification

Denial Risk

Non‑covered / investigational items

Items that do not meet the listed medical necessity criteria (including deluxe/style features that do not contribute to therapeutic function) are considered investigational and will be denied.

Billing Rule

Billing/coding — investigational codes

Specific HCPCS codes A5510 and A5508 are listed as not medically necessary/investigational and may trigger claim denials if billed.

A5510 — investigational (compression-molded inserts not total contact at dispensing)
A5508 — not medically necessary / investigational

Rigid rocker bottoms are exterior elevations with apex positioned 51%–75% of the distance from the back of the heel and located behind the metatarsal heads to reduce pressure.

Apex geometryApex is narrowed/pointed and tapers sharply to the front tip of the sole to eliminate pressure at the metatarsal heads.

RigiditySteel in the shoe provides rigidity to maintain the rocker effect and alter heel strike dynamics.

Heel designHeel tapers in the back to cause heel strike in the middle of the heel, aiding pressure redistribution.

Related type — roller bottomsRoller bottoms are similar to rocker bottoms but the heel is tapered from the apex to the front tip of the sole.

Updated all Not Medically Necessary (NMN) statements to Investigational (INV) and updated references; coding reviewed with no changes.

2023-08-25minor_review

Removed language regarding frequency of allotted numbers of shoes and inserts and some benefit language; updated shoe repair language, references, and coding tables (coding reviewed, no changes).

2022-02-03consensus_review

Consensus review with no change to the policy statement; references reviewed and updated, no coding changes.

2020-04-17consensus_review

Consensus review with no change to policy statements; coding reviewed and language revised under Product Variations, Benefit Variations, and Disclaimer sections.