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Congress amended the Medicare statutes to provide coverage, effective May 1, 1993, for depth shoes, custom-molded shoes and shoe inserts to people with diabetes who qualify under Medicare Part B.

Designed to prevent lower-limb amputations prevalent in people who have had diabetes a long time, this new Medicare benefit can prevent suffering, prolong life and save money. According to CDC, in 1990 there were over 54,000 lower limb amputations due to diabetes - - experts agree that most of these amputations are preventable with appropriate foot wear and orthosis.

The M.D. or D.O. treating the individual for diabetes must certify that

1. the individual has diabetes (ICD-9 diagnosis codes 250.00 - 250.91)

2) that the individual has one or more of the following conditions in one or both feet:

• 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
  

3) that the individual is being treated under a comprehensive plan of care for diabetes and needs therapeutic shoes and/or inserts because of conditions outlined in 1 and 2 above.

If an individual qualifies, he/she is limited to one of the following footwear categories within one calendar year:

• one pair of depth shoes and three pairs of inserts or
• one pair of custom molded shoes (including inserts) and two additional pairs of inserts

Additionally: 1) separate inserts may be covered under certain criteria; 2) a shoe modification will be covered as a substitute for an insert, and 3) a custom-molded shoe is covered when the individual has a foot deformity that cannot be accommodated by a depth shoe.

What must the physician do for individuals to receive this benefit?

The certifying physician -- the M.D. or D.O. overseeing the diabetic treatment -- must review and sign a "Statement of Certifying Physician for Therapeutic Shoes" Because this benefit is available only to people with diabetes, an appropriate ICD-9 code (250.00-250.91) is required when completing this form.

and

In addition, the prescribing physician -- the D.P.M. or M.D. -- must complete a footwear prescription.

Once the individual has the signed statement and the prescription, he/she can see a podiatrist, orthotist, prosthetist or pedorthist to have the prescription filled. The supplier will then submit the Medicare claim form (Form HCFA 1500) to the appropriate Durable Medical Equipment Regional Carrier (DMERC), keeping copies of the claim form and the original statement and prescription.

How does the individual pay for this service?

The Health Care Financing Administration (HCFA) will pay for 80 percent of the payment amount. The individual is responsible for a minimum of 20 percent of the total payment amount and possibly more if the dispenser is not accepting assignment and the dispenser's usual fee is higher than the payment amount.

The maximum payment amounts per pair in 1995 are: