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Effective Date: 06/01/2007 |
Title: Diabetic Shoes & Shoe Inserts
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Revision Date: 02/11/2021
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Document: BI198:00
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CPT Code(s): A5500-A5501; A5503-A5508; A5510; A5512-A5514; K0903; L3000; L3030
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Public Statement
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Effective Date:
a)
This policy will apply to
all services performed on or after the above revision date which will become the
new effective date.
b)
For all services referred
to in this policy that were performed before the revision date, contact customer
service for the rules that would apply.
1)
Most benefit plans
exclude coverage of orthopedic shoes, foot orthotics or other supportive devices
of the feet, except diabetics. (Please refer to your plan documents).
2)
For diabetics who have
the foot complications listed under the Medical Policy Statement section, there is a limit on the number of
foot orthotics that will be covered:
a)
Shoes: Two (2) pairs or a
combined total of four (4) units per year if under 18 years of age; otherwise,
one (1) pair or a combined total of two (2) units per year.
b)
Shoe inserts: Two (2)
pairs or a combined total of four (4) units of diabetic custom molded shoe
inserts per year.
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Medical Statement
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1)
QualChoice considers
therapeutic shoes (depth or custom-molded) along with inserts medically
necessary for members with diabetes mellitus with any of the following
complications involving the foot:
a)
Peripheral neuropathy
involving the feet; or
b)
History of pre-ulcerative
calluses; or
c)
History of previous
ulceration; or
d)
Foot deformity; or
e)
Previous amputation of
the foot or part of the foot.
2)
In general the following
services will be covered for diabetics, when meeting above medical necessity
criteria:
a)
A5500 – A5507, Diabetic
shoes
b)
A5510 – A5513, Diabetic,
custom molded foot orthotics
c)
L3000 – L3003, L3010,
L3020 and L3030 – L3031 Custom Molded Orthotics
Codes
Used In This BI:
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ACTIVE
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A5500
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For
diabetics only, fitting, custom prep & supply of off-the-shelf
depth-inlay shoe manufactured to accommodate multidensity insert(s), per
shoe
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A5501
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For
diabetics only, fitting, custom prep & supply of shoe molded frm cast(s)
of patient`s foot (custom molded shoe), per shoe
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A5503
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For
diabetics only, modification (incl fitting) of off-the-shelf depth-inlay
shoe or custom molded shoe w/roller or rigid rocker bottom, per shoe
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A5504
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For
diabetics only, modification (incl fitting) of off-the-shelf depth-inlay
shoe or custom molded shoe w/wedge(s), per shoe
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A5505
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For
diabetics only, modification (incl fitting) of off-the-shelf depth-inlay
shoe or custom molded shoe w/metatarsal bar, per shoe
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A5506
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For
diabetics only, modification (incl fitting) of off-the-shelf depth-inlay
shoe or custom molded shoe w/off-set heel(s), per shoe
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A5507
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For
diabetics only, NOS modification (incl fitting) of off-the-shelf
depth-inlay shoe or custom molded shoe, per shoe
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A5508
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For
diabetics only, deluxe feature of off-the-shelf depth-inlay shoe or
custom molded shoe, per shoe
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A5510
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For
diabetics only, direct formed, compression molded to patient`s foot w/o
external heat source, mult-density insert(s), prefab, per shoe
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A5512
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For
diabetics only, mult density insert, direct formed, molded to foot after
external heat source of 230 degrees Fahrenheit or higher, total contact
w/patient`s foot, incl arch, base layer min of 1/4 in material of Shore
A 35 durometer or 3/16 in material of Shore A 40 durometer (or higher),
prefab, ea
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A5513
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For
diabetics only, mult density insert, custom molded frm model of a
patient`s foot, total contact w/patient`s foot, incl arch, base layer
min of 3/16 in material of Shore A 35 durometer (or higher), incl arch
filler & other shaping material, custom fab, ea
(code revised 1/1/19)
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A5514
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DIAB ONLY MX DEN
INSRT DIRECT CARV CUSTOM FAB EA (new 1/1/2019)
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L3000
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Foot
insert, removable, molded to patient model, UCB type, Berkley shell, ea
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L3001
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Foot
insert, removable, molded to patient model, Spenco, ea
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L3002
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Foot
insert, removable, molded to patient model, Plastazote or equal, ea
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L3003
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Foot
insert, removable, molded to patient model, silicone gel, ea
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L3010
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Foot
insert, removable, molded to patient model, longitudinal arch support,
ea
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L3020
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Foot
insert, removable, molded to patient model, longitudinal/metatarsal
support, ea
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L3030
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Foot
insert, removable, formed to patient foot, ea
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L3031
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Foot,
insert/plate, removable, addtn to lower extrm orthotic, high strength,
lightweight material, all hybrid lamination/prepeg composite, ea
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DELETED
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K0903
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Diab
only MX den insert dir carv custom fab each
(code deleted
1/1/19)
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Limits
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1)
Two (2)
pairs or a combined total 4 units of diabetic shoes per year if under 18 years
of age; otherwise, one (1) pair or a combined total 2 units per year.
2)
Two (2)
pairs or a combined total 4 units of diabetic custom molded shoe inserts per
year.
3)
For a shoe
attached to a leg brace, it must be included in the cost of the brace.
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Background
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Soft
or flexible foot orthoses are made from soft compressible materials, such as
leather, cork, rubber, soft plastics, or plastic foam (Spenco, PPT, Pelite).
Many of these are commercially available and used for simple problems. Soft
orthotics help to absorb shock, increase balance, and take pressure off
uncomfortable or sore spots. Soft foot orthoses are worn against the sole of
the foot and are usually fabricated in full length from heel to toe with
increased thickness where weight bearing is indicated and relief where no or
little pressure should occur. Plastic foam orthoses are available in different
density and thickness and are commonly used for ischemic, insensate, ulcerated,
and arthritic feet. The advantage of any soft orthotic is that it may be easily
adjusted to changing weight-bearing forces. The disadvantage is that it must be
replaced more often than rigid orthotics. A soft orthotic is particularly
effective for diabetes. Soft orthotics is also widely used in the care of
healing ulcers in the insensate foot.
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Reference
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Addendum:
1.
Effective 01/01/2017:
Specific diabetic complication codes were added related to peripheral
neuropathy, peripheral vascular insufficiency, and ulcerations.
2.
Effective 07/01/2017:
Codes updated. Added
L3001-L3003, L3010, L3020, and L3031.
3.
Effective 01/01/2018:
Clarified verbiage in
public policy statement.
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Application to Products
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This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
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Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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