CurrentHighmark Blueshield NenyPolicy N/A

Therapeutic shoes for patients with diabetes — Certificate of Medical Necessity

This Certificate of Medical Necessity (CMN) documents clinical indications and certification requirements for therapeutic shoes/extra-depth or custom-molded shoes for patients with diabetes and is intended for providers certifying medical necessity.

Policy Summary

PayerHighmark Blueshield Neny

PolicyTherapeutic shoes for patients with diabetes — Certificate of Medical Necessity

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and sign the CMN and attach a typed office note documenting diagnosis and qualifying findings before submission.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8listed diabetes-related qualifying conditions

1required supporting document

1certifying MD/DO required

Coverage and Medical Necessity Criteria

Medical necessity criteria

Covered when ALL of the following are documented on the CMN and supporting office note:

Criteria for medical necessity: 1) Patient has diabetes mellitus; 2) Patient has one or more listed qualifying conditions (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; or foot drop); 3) Patient is under a comprehensive plan of care for diabetes managed by the certifying physician; 4) The certifying physician is an MD or DO; 5) The physician documents that the patient needs special shoes (extra-depth or custom-molded) because of his/her diabetes; 6) The CMN is completed and signed by the physician (stamps not acceptable) and accompanied by a typed office note with pertinent information.

All items must be documented on the CMN and supported by the typed office note as indicated on the form.

The CMN form does not list any explicit exclusions. The form is structured to document qualifying indications and physician attestation rather than to enumerate conditions that would automatically preclude coverage.

Coverage depends on documentation of diabetes and one or more qualifying conditions, completion and signature of the certifying physician on the CMN, and a supporting typed office note. Therefore, absence of a documented diagnosis of diabetes mellitus, failure to identify at least one listed qualifying condition (for example: prior amputation, previous ulceration, pre‑ulcerative callus, peripheral neuropathy with callus, foot deformity, poor circulation, hemiplegia/hemiparesis, or foot drop), a missing or unsigned physician signature on the CMN, or lack of evidence that the patient is under a comprehensive diabetes plan of care may render the request unsupported and subject to denial.

Policy Summary

PayerHighmark Blueshield Neny

PolicyTherapeutic shoes for patients with diabetes — Certificate of Medical Necessity

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and sign the CMN and attach a typed office note documenting diagnosis and qualifying findings before submission.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Required Documentation and Provider Responsibilities

Documentation Required

CMN and Typed Office Note Required

The certifying physician must complete and sign the Certificate of Medical Necessity (CMN) and attach a typed office note documenting the diabetes diagnosis and qualifying findings before submission.

Must include a completed CMN with physician signature (stamped signatures not acceptable).
Attach a typed office note with pertinent clinical information confirming diabetes and one or more qualifying conditions (e.g., prior amputation, prior ulceration, pre‑ulcerative callus, peripheral neuropathy with callus, foot deformity, poor circulation, hemiplegia/hemiparesis, foot drop).
Certifying physician must be an MD or DO and actively managing the patient’s diabetes; documentation must state that the physician is managing the diabetes and specify the qualifying condition(s).
Provider must indicate who is prescribing the therapeutic shoes (name and credentials).

Prior Authorization

Provider must ensure the CMN questions are fully answered and that the typed office note addresses the items on the CMN (history of amputation, prior ulceration, pre‑ulcerative signs, neuropathy with callus, foot deformity, poor circulation, hemiplegia/hemiparesis, foot drop) and affirms the patient is under a comprehensive plan of care for diabetes.

If the CMN or office note is incomplete or missing documentation of diabetes plus at least one qualifying condition, the request may be denied.
Include the prescribing provider’s name and credentials on the CMN.

Denial Risk

Missing Qualifying Condition — Denial Risk

Failure to document diabetes and one or more qualifying conditions (as listed on the CMN) or failure to have the certifying physician document that they are managing the diabetes may result in denial of coverage.

Stamped physician signatures are not acceptable — original or electronic signature required.
Typed office note must be contemporaneous and include clinical findings supporting medical necessity.

Documentation Required

Required Documentation

Required documentation checklist: completed and signed CMN, typed office note with pertinent clinical information, statement that certifying physician is MD/DO managing the patient’s diabetes, and prescriber name/credentials.

CMN completed and signed by certifying physician (no stamps).
Typed office note documenting diagnosis and qualifying findings.
Statement that certifying physician is managing the patient’s diabetes and is an MD or DO.
Prescribing clinician name and credentials.

OpenPayer

Therapeutic shoes for patients with diabetes — Certificate of Medical Necessity

Coverage and Medical Necessity Criteria

Coding and Quantitative Requirements

Required Documentation and Provider Responsibilities

Definitions and Roles

Clinical Background