Anthem Blue Cross Connecticut CG-DME-19 Therapeutic Shoes, Inserts or Modifications for Individuals with Diabetes Form

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

Clinical Indications

Medically Necessary:

1. 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 loss of protective sensation in the foot and with evidence of callus formation of either foot; or
      5. Foot deformity of either foot; or
      6. Peripheral vascular disease involving the treated foot; and
   3. The physician who is managing the individual’s systemic diabetes condition has certified that indications (A) and (B) above are met and that they are treating the individual under a comprehensive plan of care for their diabetes and that the individual needs therapeutic shoes, inserts or modifications to therapeutic shoes.
2. A custom-molded shoe is considered medically necessary when the individual has a foot deformity that cannot be accommodated by a depth shoe.
3. 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

Not Medically Necessary:

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