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Avoiding Fraud and Waste with Diabetic Therapeutic Footwear

Criteria for a diabetic patient’s therapeutic footwear.

Since 1993 Medicare has covered therapeutic shoes for diabetic patients. Within 5 years of the benefit’s availability, a report from the Office of the Inspector General of the United States found that 57% of paid claims had missing or inadequate documentation, while an audit of beneficiaries found that 3% were not diagnosed with diabetes, 12% did not meet the qualifying conditions, and 47% denied having a foot deformity or previous amputation. Companies and providers have subsequently been fined due to incidents of fraud and abuse. This article is a reminder of the qualifying criteria for footwear coverage for Medicare beneficiaries.

To qualify for footwear coverage under Medicare, the beneficiary must have diabetes plus one of the following: “neuropathy with evidence of a callus, previous or current ulcer, previous or current pre-ulcerative callus, previous amputation, foot deformities, or poor circulation.” Medicare does not clearly define neuropathy, pre-ulcerative callus, foot deformity, or poor circulation. The treating physician must manage the patient’s diabetes under a comprehensive plan, and is required to certify that the patient has diabetes and need therapeutic shoes. Other providers can write the prescription for the therapeutic footwear, but the certifying physician must provide the documentation and personally examine the patient or verify the exam performed by another provider. This documentation must also be kept by the certifying physician.

There is a lack of evidence demonstrating the beneficial use of therapeutic footwear to reduce amputations or to prevent ulcerations and amputations; however, theoretically, preventing minor trauma and ulceration to the feet through the use of therapeutic footwear is beneficial. It has been shown that minor trauma can cause cutaneous injury and could result in amputation. It should be noted that therapeutic footwear is not the solution to preventing all foot injury and ulcerations; comprehensive preventive foot care with control of hyperglycemia, hypertension, and hyperlipidemia, along with smoking cessation is the standard method to preventing foot injury and its potential ulcerations and amputations. This comprehensive foot care includes foot assessments by the physician at every visit and patient education.

The diabetes care physician should be the one to assess the foot and recommend the initiation of therapeutic shoes for patients who meet the criteria. The physician should clearly document the need and the qualifying criteria, and should not sign off any request forms from footwear companies or patients until they have fully examined the patient’s feet. Medicare will also need to clearly define neuropathy, pre-ulcerative callus, foot deformity, and poor circulation, in order to aid physicians in making their decisions and prevent fraud and waste.

Practice Pearls:

  • To qualify for footwear coverage under Medicare, the beneficiary must have diabetes plus: neuropathy with evidence of a callus, previous or current ulcer, previous or current pre-ulcerative callus, previous amputation, foot deformities, or poor circulation.
  • The certifying physician needs to document the foot assessment, need for therapeutic footwear, and the criteria that meet Medicare’s qualification.
  • Medicare will need to clearly define neuropathy, pre-ulcerative callus, foot deformity, and poor circulation in order to further prevent fraud and waste.

Brunner JE. Does Your Patient Need Diabetic Therapeutic Footwear? (Where Benefit, Evidence, and Bureaucracy Collide). Clinical Diabetes. 2015; 22(2): 51-53.