This document addresses orthopedic footwear including shoes, inserts and modification to shoes for individuals who do not have diabetes.

Note: For additional information refer to CG-DME-19 Therapeutic Shoes, Inserts or Modifications for Individuals with Diabetes.

Medically Necessary: 

Shoes, inserts, and modifications are considered medically necessary only in the limited circumstances described below: 

• Shoes are considered medically necessary if they are an integral part of a leg brace that is medically necessary.
• Heel replacements, sole replacements and shoe transfers involving shoes on a medically necessary leg brace are also considered medically necessary.
• Inserts and other shoe modifications (such as lifts, wedges, arch supports and other additions) are considered medically necessary if they are on a shoe that is an integral part of a medically necessary leg brace, if they are medically necessary for the proper functioning of the brace.
• Prosthetic shoes are considered medically necessary if they are an integral part of a prosthesis for individuals with a partial foot amputation.

Not Medically Necessary:

Orthopedic footwear that does not meet the criteria above is considered not medically necessary.

A matching shoe that is not attached to a brace and items related to that shoe are considered not medically necessary.

Shoes are considered not medically necessary when they are put on over partial foot prosthesis or other lower extremity prosthesis that is attached to the residual limb by mechanisms other than being an integral part of the prosthesis.

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.

This clinical guideline is based on Centers for Medicare and Medicaid Services (CMS) criteria.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination: Durable medical equipment reference list. NCD #280.1. 05/05/2005. Available at: https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?list_type=ncd. Accessed on September 08, 2011
2. CGS Administrators, LLC. Jurisdiction C. Local Coverage Determination for Orthopedic Footwear (L11445). Revised 08/04/2011. Available at: http://www.cms.hhs.gov/mcd/index_local_alpha.asp?from2=index_local_alpha.asp&from=alphalmrp&letter=A&. Accessed on September 08, 2011.
3. National Government Services, Inc. Jurisdiction B. Local Coverage Determination for Orthopedic Footwear (L27220). Revised 07/30/2009. Available at: http://www.cms.hhs.gov/mcd/index_local_alpha.asp?from2=index_local_alpha.asp&from=alphalmrp&letter=A&. Accessed on September 8, 2011.
4. NIHC Corp. Jurisdiction A. Local Coverage Determination for Orthopedic Footwear (L11467). Revised 07/23/2009. Available at: http://www.cms.hhs.gov/mcd/index_local_alpha.asp?from2=index_local_alpha.asp&from=alphalmrp&letter=A&. Accessed on September 08, 2011.
5. Noridian Administrative Services. Jurisdiction D. Local Coverage Determination for Orthopedic Footwear (L11456). Revised 07/26/2009. Available at: http://www.cms.hhs.gov/mcd/index_local_alpha.asp?from2=index_local_alpha.asp&from=alphalmrp&letter=A&. Accessed on September 8, 2011.

Orthopedic Footwear