Anthem Blue Cross Connecticut CG-DME-20 Orthopedic Footwear Form

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

Note: Please see the following related document for additional information:

• CG-DME-19 Therapeutic Shoes, Inserts or Modifications for Individuals with Diabetes

Clinical Indications

Medically Necessary:

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

1. Shoes are considered medically necessary if they are an integral part of a leg brace that is medically necessary.
2. Heel replacements, sole replacements and shoe transfers involving shoes on a medically necessary leg brace are also considered medically necessary.
3. 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.
4. 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.