Clinical Guideline - Therapeutic Shoes, Inserts or Modifications for Individuals with Diabetes PDF Print E-mail

1. Description

This document addresses therapeutic shoes, inserts, and modifications to therapeutic shoes for individuals with diabetes. Therapeutic shoes may be custom-molded or depth shoes.

2. Clinical Indications

2.1. Medically Necessary:

Therapeutic shoes, inserts or modifications to therapeutic shoes are considered medically necessary if the following criteria are met:

  1. The individual has diabetes mellitus; and
  2. The individual has one or more of the following conditions:
    1. previous amputation of the other foot or part of either foot, or
    2. history of previous foot ulceration of either foot, or
    3. history of pre-ulcerative calluses of either foot, or
    4. peripheral neuropathy with evidence of callus formation of either foot, or
    5. foot deformity of either foot, or
    6. poor circulation in either foot
  3. The certifying physician who is managing the individual's systemic diabetes condition has certified that indications (1) and (2) above are met and that he/she is treating the individual under a comprehensive plan of care for his/her diabetes and that the individual needs therapeutic shoes, inserts or modifications to therapeutic shoes.

A custom-molded shoe is considered medically necessary when the individual has a foot deformity that cannot be accommodated by a depth shoe.

A modification of a custom-molded or depth shoe is considered medically necessary as a substitute for an insert. Although not intended as a comprehensive list, the following are the most common shoe modifications:

  1. rigid rocker bottoms
  2. roller bottoms
  3. wedges
  4. metatarsal bars
  5. offset heels

2.2. Not Medically Necessary:

Any shoes, shoe inserts or modifications that do not meet the above criteria are considered not medically necessary.

 

3. Discussion/General Information

Diabetes is a chronic illness in which the body does not properly produce or use insulin. Foot ulcerations, peripheral neuropathy and lower extremity amputations are some of the common consequences of diabetes. Effective management of these factors can assist in the prevention of or delay of adverse outcomes.

Definitions

Custom-molded shoe: a shoe that

  • is constructed over a positive model of the individual's foot
  • is made from leather or other suitable material of equal quality
  • has removable inserts that can be altered or replaced as the individual's condition warrants
  • has some form of shoe closure.

This includes a shoe with or without an internally seamless toe.

Depth shoe: a shoe that

  • has a full length, heel-to-toe filler that, when removed, provides a minimum of 3/16 inch of additional depth used to accommodate custom-molded or customized inserts
  • is made from leather or other suitable material of equal quality
  • has some form of shoe closure
  • is available in full and half sizes with a minimum of three widths so that the sole is graded to the size and width of the upper portions of the shoe according to the American standard last sizing schedule or its equivalent

This includes a shoe with or without an internally seamless toe.

The American last sizing schedule is the numerical shoe sizing system used for shoes in the United States.

Metatarsal bars: exterior bars that are placed behind the metatarsal heads in order to remove pressure from the metatarsal heads. The bars are of various shapes, heights, and construction depending on the exact purpose.

Offset heel: a heel flanged at its base either in the middle, to the side, or a combination, that is then extended upward to the shoe in order to stabilize extreme positions of the hind foot.

Rigid rocker bottoms: exterior elevations with apex position for 51% to 75% distance measured from the back end of the heel. The apex is a narrowed or pointed end of an anatomical structure. The apex must be positioned behind the metatarsal heads and taper off sharply to the front tip of the sole. Apex height helps to eliminate pressure at the metatarsal heads. Rigidity is ensured by the steel in the shoe. The heel of the shoe tapers off in the back in order to cause the heel to strike in the middle of the heel.

Roller bottoms (sole or bar): the same as rocker bottoms except the heel is tapered from the apex to the front tip of the sole.

Wedges (posting): are either for hindfoot, forefoot, or both and may be in the middle or to the side. The function is to shift or transfer weight bearing upon standing or during ambulation to the opposite side for added support, stabilization, equalized weight distribution, or balance.

The therapeutic shoe insert for diabetics described by HCPCS code A5512 is a total contact, multiple density, prefabricated, removable inlay that is directly molded to the individual's foot so that it conforms to the plantar surface and makes total contact with the foot, including the arch. The insert must retain its shape during use for the life of the insert. The material responsible for maintaining the shape of the device is called the base layer and must be heat moldable. This material usually constitutes the bottom layer of the device and must be of a sufficient thickness and durometer to maintain its shape during use (e.g., at least ¼ inch of Shore A 35 or higher, or 3/16 inch of Shore A 40 or higher). Modifications such as additional arch fill may be necessary to achieve and maintain total contact. The materials used should be suitable with regards to the individual's condition.

The therapeutic shoe insert for diabetics described by HCPCS code A5513 is a total contact, custom fabricated, multiple density removable inlay that is molded to a model of the individual's foot so that it conforms to the plantar surface and makes total contact with the foot, including the arch. The insert must retain its shape during use for the life of the insert. A custom fabricated device is made from materials that do not have predefined trim lines for heel cup height, arch height and length or toe shape. The base layer of the device must be of a sufficient thickness and durometer to maintain its shape during use (e.g., at least 3/16 inch of Shore A 35 material or higher). The base layer is allowed to be thinner in the custom fabricated device because appropriate arch fill or other additional material will be layered up individually to maintain shape and achieve total contact. The central portion of the base layer of the heel may be thinner (but at least 1/16 inch) to allow for greater pressure reduction. The specified thickness of the lateral portions of the base layer must extend from the heel through the distal metatarsals and may be absent at the toes. The top layer of the device may be of a lower durometer and must also be heat moldable. The materials used should be suitable with regards to the individual's condition.

4. Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS
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, minimum of ¼ inch material of shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each
A5513 For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer or higher, includes arch filler and other shaping material, custom fabricated, each
ICD-9 Diagnosis
249.00-249.91 Secondary diabetes mellitus
250.00-250.93 Diabetes mellitus

article reference: http://www.empireblue.com/medicalpolicies/guidelines/gl_pw_a053655.htm

 

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