Diabetic Shoes
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Defines prior authorization, documentation, and medical necessity criteria Longevity Health Plan uses to cover therapeutic shoes and inserts for members with diabetes; applies to providers submitting requests for beneficiaries in the Plan.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Initial Coverage Criteria
Covered when ALL of the following are met:
Clinical notes must document diabetes diagnosis and objective foot findings (e.g., pedal pulses, foot condition).
Diagnoses such as hypertension, coronary artery disease, congestive heart failure, or edema alone are insufficient without objective foot findings.
Bed‑confined members are not appropriate for therapeutic shoes and requests will be denied.
Covered with criteria
Therapeutic shoes, inserts and/or modifications are covered when ALL of the following are met:
If any of criteria 1–5 are not met, items will be denied as noncovered.
Quantity limits
Quantity and substitution limits within one calendar year:
Quantities greater than those listed will be denied as noncovered. Inserts represented by A5510, deluxe features (A5508), and inserts used in noncovered shoes are noncovered.
Members who are bed confined are excluded from coverage for therapeutic shoes. Bed confined is defined as any beneficiary who does not leave his or her bed to sit elsewhere or ambulate. Additionally, the presence of systemic diagnoses such as hypertension, coronary artery disease, congestive heart failure, or edema alone does not meet coverage criteria; documentation must include objective and quantifying foot findings (for example, pedal pulses or a clear description of the condition of the foot/feet).
Requests that lack required documentation demonstrating non–bed-confined status or objective foot findings may be denied.
Certain HCPCS codes and features are specifically noncovered. Inserts represented by A5510 (inserts that achieve compression molding to the beneficiary’s foot over time) are denied because they are not total contact at dispensing. Deluxe features of diabetic shoes (A5508) are also denied as noncovered. Common shoe modifications such as rigid rocker or roller bottoms (A5503), wedges (A5504), metatarsal bars (A5505), and offset heels (A5506) are listed as allowable modifications when appropriately documented; other modifications are billed under A5507.
Inserts provided with noncovered shoes are noncovered, and quantities or features exceeding the policy limits will be denied.
No additional explicit exclusions are specified in the provided excerpt beyond those noted elsewhere in the policy (for example, bed-confined beneficiaries and specific noncovered codes/features).
Providing therapeutic shoes to beneficiaries who are bed confined is not appropriate and will not meet medical necessity criteria. Bed confined beneficiaries—those who do not leave their bed to sit elsewhere or ambulate—are excluded from this benefit.
A custom molded shoe (A5501) requires documentation in the supplier’s records that clearly describes the nature and severity of the foot deformity that cannot be accommodated by a depth shoe. If the medical record does not document why a custom molded shoe is medically necessary, the item will be denied as not reasonable and necessary.
No separate not‑medically‑necessary statements are present in the provided excerpt beyond those captured in the policy’s denial rules (for example, denials when documentation is insufficient or when beneficiaries are bed confined).
Referenced Codes and Visit Timeframes
| L33369 | Therapeutic Shoes for Persons with Diabetes (LCD identifier) |
| A52501 | Therapeutic Shoes for Persons with Diabetes - Policy Article |
| A5501 | Custom molded shoe |
| A5500 | Depth shoe |
| A5512 | Insert (specific type) |
| A5513 | Insert (specific type) |
| A5514 | Insert (specific type) |
| A5503 | Rigid rocker bottom/roller bottom modification |
| A5504 | Wedges |
| A5505 | Metatarsal bars |
| A5506 | Offset heels |
| A5507 | Other modifications to diabetic shoes |
Prior Auth, Documentation, and Billing Requirements
Prior authorization required (aligns to LCD L33369 / A52501)
Prior authorization is required for therapeutic shoes for diabetes; Longevity Health aligns its requirements to LCD L33369 and Policy Article A52501. Providers must obtain prior authorization through the Plan before providing these items.
Standard Written Order (SWO) must be provided before billing
A Standard Written Order (SWO) must be communicated to the supplier prior to claim submission; if the supplier bills without first receiving the SWO, the item will be denied as statutorily noncovered.
- Electronic evidence of the SWO is acceptable.
Prior authorization details not specified in excerpt
No additional prior authorization details are specified in this excerpt beyond the Plan’s requirement to align with LCD L33369 and Policy Article A52501.
Reserved provider action
Reserved for provider action content (no specific requirement listed in source).
Yearly quantity limits — overages denied
Quantities exceeding the listed yearly limits will be denied as noncovered. Yearly limits are either one pair custom molded shoes (A5501) plus 2 additional pairs of inserts (A5512/A5513/A5514), or one pair depth shoes (A5500) plus 3 pairs of inserts (A5512/A5513/A5514); modifications may substitute for an insert.
Step-therapy not specified in excerpt
No step-therapy requirements are specified in this excerpt.
Required documentation: SWO and in‑person clinical notes within 6 months
Provider must submit a Standard Written Order (electronic acceptable) and clinical notes from an in-person visit with a certifying physician within six months prior to delivery documenting diagnosis of diabetes and objective foot findings.
- Clinical notes must document diabetes diagnosis and objective information (e.g., pedal pulses or condition of the foot).
- Evidence of the SWO may be electronic.
Supervising and certifying physician documentation requirements
The supervising physician must document that the beneficiary is diabetic and provide ongoing follow-up under a comprehensive management program; the certifying physician (M.D. or D.O.) must document one or more qualifying foot conditions and sign the certification after an in‑person visit within required timeframes.
- Certifying physician must be an M.D. or D.O. (may not be a podiatrist or clinical nurse specialist unless 'incident to' rules are met).
- For claims on/after 1/1/2011: have an in-person visit addressing diabetes within 6 months prior to delivery and sign certification on/after that visit and within 3 months prior to delivery.
Documentation details not specified in excerpt
No additional documentation requirements are specified in this excerpt beyond the SWO and in‑person visit documentation noted elsewhere.
Denial triggers: missing documentation or bed‑confined members
Requests lacking required documentation (e.g., written order, clinical notes) or for bed‑confined members may be denied. If criteria 1–5 (diabetes diagnosis; qualifying foot condition; certifying physician certification; supplier in‑person evaluation prior to selection; and objective fit assessment at delivery) are not met, items will be denied as noncovered.
- Members who are bed confined (do not leave bed to sit elsewhere or ambulate) are not appropriate candidates and requests may be denied.
- Custom molded shoes provided without documentation of the nature and severity of the deformity will be denied as not reasonable and necessary.
Billing denial conditions: no SWO or insufficient custom‑shoe documentation
Claims billed without a Standard Written Order (SWO) or lacking required documentation for custom molded shoes (e.g., why the deformity requires a custom molded shoe) will be denied as statutorily noncovered or not reasonable and necessary.
- Supplier billing without first receiving the SWO will be denied as statutorily noncovered.
- If medical record does not document why a custom molded shoe is medically necessary, the claim will be denied.
No further denial triggers specified in excerpt
No explicit additional denial triggers are present in these chunks beyond those already described (missing SWO/clinical documentation, bed‑confined status, unmet criteria 1–5).
Clinical Background and Rationale
Therapeutic shoes and removable inserts are prescribed to reduce the risk of ulceration and injury in persons with diabetes who have qualifying foot conditions. Coverage is targeted to beneficiaries with diabetes plus one or more qualifying foot findings (for example: amputation of the other foot or part of either foot; history of foot ulceration; history of pre‑ulcerative calluses; peripheral neuropathy with evidence of callus formation; foot deformity; or poor circulation). The purpose of these items is to protect the foot, accommodate deformity, and reduce pressure points that can lead to skin breakdown and ulceration.
Key Terms and Roles
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