Medical Policy
Effective Date:06/01/2007 Title:Diabetic Shoes & Shoe Inserts
Revision Date:02/11/2021 Document:BI198:00
CPT Code(s):A5500-A5501; A5503-A5508; A5510; A5512-A5514; K0903; L3000; L3030
Public Statement

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.
Medical Statement

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:

ACTIVE

A5500

For diabetics only, fitting, custom prep & supply of off-the-shelf depth-inlay shoe manufactured to accommodate multidensity insert(s), per shoe

A5501

For diabetics only, fitting, custom prep & supply of shoe molded frm cast(s) of patient`s foot (custom molded shoe), per shoe

A5503

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

A5504

For diabetics only, modification (incl fitting) of off-the-shelf depth-inlay shoe or custom molded shoe w/wedge(s), per shoe

A5505

For diabetics only, modification (incl fitting) of off-the-shelf depth-inlay shoe or custom molded shoe w/metatarsal bar, per shoe

A5506

For diabetics only, modification (incl fitting) of off-the-shelf depth-inlay shoe or custom molded shoe w/off-set heel(s), per shoe

A5507

For diabetics only, NOS modification (incl 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 w/o external heat source, mult-density insert(s), prefab, per shoe

A5512

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

A5513

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)

A5514

DIAB ONLY MX DEN INSRT DIRECT CARV CUSTOM FAB EA (new 1/1/2019)

L3000

Foot insert, removable, molded to patient model, UCB type, Berkley shell, ea

L3001

Foot insert, removable, molded to patient model, Spenco, ea

L3002

Foot insert, removable, molded to patient model, Plastazote or equal, ea

L3003

Foot insert, removable, molded to patient model, silicone gel, ea

L3010

Foot insert, removable, molded to patient model, longitudinal arch support, ea

L3020

Foot insert, removable, molded to patient model, longitudinal/metatarsal support, ea

L3030

Foot insert, removable, formed to patient foot, ea

L3031

Foot, insert/plate, removable, addtn to lower extrm orthotic, high strength, lightweight material, all hybrid lamination/prepeg composite, ea

DELETED

K0903

Diab only MX den insert dir carv custom fab each (code deleted 1/1/19)
Limits

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.

Reference

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.

Application to Products
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.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.