Therapeutic Shoes for Diabetics Mandate Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 07|05|2007 POLICY LAST UPDATED: 12|01|2021 OVERVIEW This is an administrative policy to document the state-mandated coverage guidelines for therapeutic shoes for diabetics (§ 27-20-30, full text below).
This policy is applicable for Commercial Products only. NOTE: While this policy is not applicable to Medicare Advantage Plans Advantage Plans, therapeutic shoes for diabetics are covered for Medicare Advantage Plans members according to the Centers for Medicare and Medicaid Services (CMS) guidelines. Please refer to the members Evidence of Coverage for the applicable benefit for this service. MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION Prior authorization review is not required. POLICY STATEMENT Commercial Products Therapeutic shoes for diabetics are covered.
COVERAGE Commercial Products Benefits vary by groups/contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable diabetic equipment/supplies, medical equipment, medical supplies, and prosthetic devices coverage/benefits. BACKGROUND The Rhode Island General Law Mandate applies to Commercial Products only. Rhode Island General Law (RIGL) 27-20-30 Diabetes treatment requires: "(a) Every individual or group health insurance contract, plan, or policy delivered, issued for delivery or renewed in this state which provides medical coverage that includes coverage for physician services in a physician's office, and every policy which provides major medical or similar comprehensive-type coverage, shall include coverage for the following equipment and supplies for the treatment of insulin treated diabetes, non-insulin treated diabetes, and gestational diabetes when medically appropriate and prescribed by a physician: blood glucose monitors and blood glucose monitors for the legally blind, test strips for glucose monitors and/or visual reading, insulin, injection aids, cartridges for the legally blind, syringes, insulin pumps, and appurtenances to the pumps, insulin infusion devices, and oral agents for controlling blood sugar and therapeutic/molded shoes for the prevention of amputation. Upon the approval of new or improved diabetes equipment and supplies by the Food and Drug Administration, all policies governed by this chapter shall guarantee coverage of new diabetes equipment and supplies when medically appropriate and prescribed by a physician. These policies shall also include coverage, when medically necessary, for diabetes self-management education to ensure that persons with diabetes are instructed in the self-management DRAFT Medical Coverage Policy | Therapeutic Shoes for Diabetics Mandate

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

and treatment of their diabetes, including information on the nutritional management of diabetes. The coverage for self- management education and education relating to medical nutrition therapy shall be limited to medically necessary visits upon the diagnosis of diabetes, where a physician diagnoses a significant change in the patient's symptoms or conditions which necessitates changes in a patient's self-management, or where re-education or refresher training is necessary. This education, when medically necessary and prescribed by a physician, may be provided only by the physician or, upon his or her referral, to an appropriately licensed and certified health care provider, and may be conducted in group settings. Coverage for self- management education and education relating to medical nutrition therapy shall also include home visits when medically necessary. (b) Benefit plans offered by a hospital service corporation may impose copayment and/or deductibles for the benefits mandated by this chapter, however, in no instance shall the copayment or deductible amount be greater than the copayment or deductible amount imposed for other supplies, equipment, or physician office visits. Benefits for services under this chapter shall be reimbursed in accordance with the respective principles and mechanisms of reimbursement for each insurer, hospital, or medical service corporation, or health maintenance organization."

Therapeutic shoes for diabetics may consist of molded shoes or depth shoes and/or inserts and are specially fitted. They are designed to provide protection for feet with decreased sensation, and promote support for feet that are changing in shape and for which normal shoes would be inadequate.

Custom molded shoes are shoes that are constructed over a positive model of the patient’s foot and have removable inserts that can be changed or replaced as the patient’s condition warrants. The shoes are made of leather or other suitable material of equal quality and have some form of shoe closure.

A depth shoe has a full-length, heel-to-toe filler that, when removed, provides a minimum of 3/16" of additional depth used to accommodate custom molded or customized inserts. The shoes are made of leather or other suitable material of equal quality and have some form of shoe closure.

Inserts are a total contact, multiple density, removable inlay that is directly molded to the patient's foot or a model of the patient's foot. Generally, inserts are made from foam, polyethylene, or cork.

CODING Commercial Products The following HCPCS code(s) are covered: A5500 For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe A5501 For diabetics only, fitting (including follow-up), custom preparation and supply of shoe molded from cast(s) of patient's foot (custom-molded shoe), per shoe A5503 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom- molded shoe with roller or rigid rocker bottom, per shoe A5504 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom- molded shoe with wedge(s), per shoe A5505 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom- molded shoe with metatarsal bar, per shoe A5506 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom- molded shoe with off-set heel(s), per shoe A5507 For diabetics only, not otherwise specified modification (including 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 without external heat source, multiple-density insert(s) prefabricated, per shoe A5512 For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient's foot, including arch, base layer

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

minimum of 1/4 inch material of Shore A 35 durometer or 3/16 inch material of Shore A 40 durometer (or higher), prefabricated, each A5513 For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of Shore A 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each A5514 For diabetics only, multiple density insert, made by direct carving with cam technology from a rectified cad model created from a digitized scan of the patient, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each

RELATED POLICIES Diabetes Self-Management Education Mandate

PUBLISHED Provider Update, February 2022 Provider Update, November 2019 Provider Update, May 2018 Provider Update, October 2017 Provider Update, July 2016

REFERENCES

1. Diabetes Self-Management, Supplies, and Other Medical Services: http://www.cms.hhs.gov/DiabetesSelfManagement/Therapeutic shoes
2. CWF Edits for Inserts for Therapeutic Shoes: http://www.cms.hhs.gov/transmittals/downloads/R44OTN.pdf.

3. Rhode Island General Law (RIGL) Mandate 27-20-30. http://webserver.rilin.state.ri.us/Statutes/TITLE27/27-20/27-20-30.HTM

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   This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS