CurrentHighmark Blueshield NenyPolicy N/A

Therapeutic shoes (extra-depth or custom-molded) for patients with diabetes — Coverage Criteria and CMN requirements

Forms and documentation requirements for certifying medical necessity of therapeutic shoes (extra-depth or custom-molded) for patients with diabetes mellitus; affects ordering clinicians and suppliers submitting a Certificate of Medical Necessity (CMN).

Policy Summary

PayerHighmark Blueshield Neny

PolicyTherapeutic shoes for patients with diabetes — coverage criteria and CMN

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvide a completed CMN with a typed office note and a handwritten certifying physician signature (MD or DO).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8listed qualifying foot conditions

1required supporting doc

2011-06-28doc revision

Coverage Criteria for Therapeutic Shoes

Initial coverage criteria

Covered when ALL of the following are met:

Primary conditions

Qualifying foot conditions: One or more of: history of partial or complete foot amputation; history of previous foot ulceration; history of pre-ulcerative callus; peripheral neuropathy with evidence of callus formation; foot deformity; poor circulation; hemiplegia/hemiparesis; foot drop>=1
Circle all that apply on CMN

Care plan and need: Patient is under a comprehensive plan of care by the certifying MD or DO and needs special shoes (extra depth or custom-molded) because of diabetes

Both items are checkboxes on CMN

Policy Summary

PayerHighmark Blueshield Neny

PolicyTherapeutic shoes for patients with diabetes — coverage criteria and CMN

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvide a completed CMN with a typed office note and a handwritten certifying physician signature (MD or DO).

SourceLink

On This Page

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Although no exclusions are stated, claims will not meet the CMN-based coverage criteria if the required elements are absent. In particular, lack of documented diabetes mellitus, no circled qualifying foot condition from the list (e.g., history of amputation, prior ulceration, pre‑ulcerative callus, peripheral neuropathy with callus, foot deformity, poor circulation, hemiplegia/hemiparesis, foot drop), failure to indicate the patient is under a comprehensive plan of care, or failure to show that the patient needs special shoes (extra-depth or custom-molded) would result in not meeting criteria. Additionally, the CMN requires the certifying physician to be an MD or DO and to provide a handwritten signature; missing that signature also undermines medical necessity documentation.

Provider Responsibilities and Documentation

Documentation Required

inv-04: Certifying physician and prescriber identification

Certifying physician and prescriber identification must be clearly documented on the CMN: the certifying physician (MD or DO) who is managing the patient’s diabetes and specifying the qualifying condition must be identified by name and indicated as an MD or DO. The prescriber of the therapeutic shoes must also be named with credentials. Physician signature is required (stamps not acceptable) and date must be present.

Certifying physician (MD or DO) name and indication that they manage the patient’s diabetes
Prescriber name and credentials
Physician signature (no stamp) and date

Denial Risk

inv-05: Not addressed

If the CMN does not address required elements (see other callouts in this section), the request may be at risk for denial. Ensure all CMN fields and supporting documentation are completed; missing or incomplete CMNs should be corrected before submission.

Documentation Required

inv-06: Required supporting documentation — typed office note

A typed office note with pertinent information must accompany the CMN. The office note should describe the patient’s diagnosis, relevant diabetic foot history (e.g., prior ulceration, amputation, deformity, neuropathy, poor circulation), current comprehensive plan of care for diabetes, and the medical necessity for special shoes (extra depth or custom-molded).

Include diagnosis and relevant diabetic foot history
Document comprehensive plan of care managed by certifying MD/DO
State why special shoes are medically necessary (extra depth or custom-molded)

Documentation Required

inv-07: CMN completion requirements

Complete the CMN fully: answer all condition questions (e.g., diabetes plus one or more qualifying foot conditions), confirm the patient is under a comprehensive plan of care by the certifying MD/DO, indicate the need for special shoes due to diabetes, and identify who is prescribing the shoes. Use the CMN version referenced (Rev. 06/28/2011) and attach the typed office note.

Circle qualifying conditions present (amputation, ulceration, callus, neuropathy with callus, deformity, poor circulation, hemiplegia/hemiparesis, foot drop)
Confirm comprehensive plan of care (Y/N/D)
Confirm need for special shoes due to diabetes (Y/N/D)
Certifying physician is MD or DO (Y/N)
Prescriber name and credentials

Denial Risk

inv-08: Missing qualifying condition — denial risk if diabetes or qualifying foot condition not documented

If diabetes or a qualifying foot condition is not documented on the CMN and supporting office note, the claim is at high risk for denial. Verify that at least one qualifying foot condition is selected and that diabetes care and shoe necessity are documented.

Missing documentation of diabetes or qualifying foot condition may result in denial
Ensure at least one qualifying condition is circled and supported in the office note

Key Definitions

Therapeutic shoes definition

Qualifying featuresIntended to reduce risk of ulceration or other complications in patients with diabetes who have qualifying foot conditions (history of amputation, prior ulceration, pre-ulcerative callus, peripheral neuropathy with callus, foot deformity, poor circulation, hemiplegia/hemiparesis, or foot drop).

Types includedExtra-depth shoes and custom-molded shoes as specified on the CMN.

Documentation requirementCMN must indicate the patient needs special shoes because of diabetes (checkbox on form).

Certifying physician definition

Signature requirementMust provide a handwritten physician signature on the CMN (stamps are not acceptable).

Role on CMNCertifying physician must confirm the patient is under a comprehensive plan of care and that the patient needs special shoes because of diabetes (checkbox items).

Prescribing vs certifyingThe CMN captures both the certifying physician (MD/DO) and the identity/credentials of the clinician prescribing the therapeutic shoes.

Background

Therapeutic shoes (extra‑depth or custom‑molded) are intended to reduce the risk of foot ulcers and complications in patients with diabetes who have high‑risk foot findings. The CMN requires documentation that the patient has diabetes mellitus and at least one qualifying foot condition (the form lists eight specific findings), is managed under a comprehensive plan of care by the certifying MD or DO, and needs special shoes because of diabetes. These elements together provide the clinical rationale that extra‑depth or custom‑molded footwear is necessary to prevent harm (for example, recurrent ulceration or amputation) in a high‑risk diabetic foot.