How to Properly Obtain Diabetic Shoes to Stay Healthy and Remain Medicare Compliant

Medicare has created a great program for diabetics that will cover up to eighty percent of the cost of a special shoe and set of inserts to help avoid shoe-related skin complications seen often in diabetics. Unfortunately, there are many companies who are all too willing to provide this service for diabetics strictly as a profit-making measure. These companies lack employees who have first-hand knowledge about an individual's foot, and lack the expertise to properly fit and select a proper shoe and insert for that individual.

This article will discuss the complex need a diabetic has in regards to properly fitting shoes, and why an unqualified company or medical supply store should never prompt a diabetic into shoes that may not be appropriate for their individual foot.

Medicare's Therapeutic Shoe Bill was passed as a direct recognition of the need for protection of diabetic feet. Simply put, diabetics generally have poor sensation, and a poorly fitting shoe will cause abnormal rubbing of the skin. Normally, this would cause pain in someone with good sensation. However, diabetics may not feel this pain, and the friction and pressure on the skin will eventually produce skin sores. Even if the shoe is properly sized, a foot that has a deformity to it (like bunions and hammertoes) can produce the same result.

Diabetics do not heal wounds easily, and infections of skin sores is much more common. Over the years, this has lead to a great number of amputations. Medicare recognized the need to prevent this from both a patient protection stance as well as a cost savings stance (amputation care is expensive). Therefore, the shoe bill was created to provide this service. A therapeutic shoe is essentially an extra deep shoe built to properly fit the foot and toes along the top and sides combined with a special insert of minimal thickness that will reduce pressure and friction on the bottom of the foot. The inserts can be simply heat molded to match the foot skin, or it can be custom made to the individual foot.

Less commonly, a therapeutic shoe can be a custom-made shoe for those with severe foot deformity that even an extra depth shoe cannot accommodate. However, Medicare decided to limit who could actually receive coverage of these shoes, as all diabetics do not necessarily have an absolute need for protection. Medicare's policy allows for coverage of one pair of extra depth shoes with three pairs of inserts each calendar year, or one pair of custom shoes and two pairs of additional custom inserts. In order to qualify for these shoes, a diabetic must be under a comprehensive treatment program by a physician for their diabetes (some form of diabetes control, testing blood work regularly etc.), and must have at least one of the following in their feet:

- Partial or complete foot amputation

- Past foot ulcers Calluses or corns that could lead to foot ulcers

- Nerve damage because of diabetes with signs of problems with calluses or corns

- Poor circulation

- Deformed foot (bunions, hammertoes, very flat or high-arched feet, protruding bone spurs, etc.)

A prescription must be made by a podiatrist (physician specializing in the foot and ankle) or other suitable physician after a proper assessment of the foot for these shoes, and the shoes must be dispensed by a physician or other qualified individual like a prosthetist, pedorthist, or orthotist. The physician treating the diabetes will be required to sign a statement certifying the need for the shoes and agreeing with the findings of the podiatrist (or their own findings if a podiatrist is not available) Without all these things, Medicare will not and should not cover diabetic shoes.

The foot exam portion of this is vital, as the foot is a very complex piece of biological engineering that goes well beyond simply length and width. A thorough knowledge of how the foot mechanically functions is key in selecting the proper shoe and the proper insert to accommodate the foot as it functions during the walking cycle. With the exception of a highly qualified pedorthist, prosthetist, or orthotist, only a podiatrist has enough training and expertise to make this assessment. Even one's internist or family physician lacks this expertise regarding the foot, but will do in a pinch if a podiatrist is not available for the purpose of staying complaint with Medicare's qualifying rules.

When diabetics receive their diabetic shoes in this way, they can be reasonably assured that a proper shoe and insert was selected and dispensed, and it is reasonable to assume that the fit and function of this shoe will be continuously monitored by at least the podiatrist, if not to some degree by the physician treating the diabetes. Unfortunately, this system seems to break down when pharmacies and medical supply companies try to 'get in on the action'.

These companies will solicit an individual directly from diabetic supply lists or indirectly through community advertising, and offer a 'free' pair of shoes: no foot exam, no qualified physician pouring over every aspect of the individual foot's function and structure, and no one to properly assess for the qualifying findings that have too be present (wounds, foot deformity, poor sensation etc.). One is simply measured for a pair of shoes based strictly on size, and an insert is selected (usually the custom fitted insert because Medicare pays more for it). After a while, the shoes and inserts are delivered to the patient's home and no one is there to ensure a proper fit, or even to monitor the foot after awhile to ensure the shoe is properly functioning as a protective device.

The shoes and inserts may even be of substandard material or may barely qualify under the guidelines Medicare has set specifically for these shoes. Pharmacies and medical supply companies can get away with this because of one key part of the required paperwork: the certifying statement. Like podiatrists who dispense diabetic shoes, these companies submit a certifying statement to the physician treating the diabetes, who must agree with the findings (which may be pre-printed on a form letter). A busy physician may not have the time to pour through a patient's chart to see if calluses, foot deformity, poor sensation etc. were present (and he/she most likely won't have that specific information unless there has been a major foot problem in the past they were assessing). The physician will then likely sign the certifying statement out of desire to do good for their patient. The statement in all likelihood will need to also contain wording that doubles as the prescription for the shoes and inserts.

In essence, the diabetes-treating physician prescribes and certifies the shoes and inserts in this process at the behest of the companies trying to sell the shoes. Sometimes an astute physician will refuse this request until a proper foot exam is performed, but this is the exception. When a podiatrist sends this certifying statement to the other physician, the assumption is always that the podiatrist performed the foot exam, found the listed findings, and the physician treating the diabetes can rely on those findings to agree with the certifying statement.

Recently, Medicare has clarified it's policy and the physician treating the diabetes must have written information in their chart confirming the podiatrist's findings, or in the case of shoes obtained by a company, confirming whatever they write on the certifying statement they send out. The chart note has to be made available for Medicare to review on demand. This new clarification may close the loophole that supply companies and pharmacies have found to exploit busy internists, family physicians, and endocrinologists.

In summary, the process of diabetics obtaining diabetic shoes is complicated. The need must be there, and all of Medicare's required qualifications and steps must be met. The shoes and inserts themselves must be selected after a careful assessment of the foot's shape and function, and the feet need to be monitored to ensure the shoes and inserts are performing their jobs.

Pharmacies and medical supply companies who only in essence dispense a shoe-size fitted shoe and insert without exam or follow-up have no business being the initiators of this process, as profit is generally the only motivation for this service. A diabetic's podiatrist and treating physician have a direct ethical desire and stake in preventing disease and foot complications, and should be the only initiators of this process. A pharmacy or medical supply company can then supply the diabetic shoes if a more traditional provider is not found (like a prosthetist/orthotist or the podiatrist themselves), but only at the behest of the podiatrist/physician making a medical decision, and not the other way around.

Dr. Kilberg provides compassionate and complete foot and ankle care to adults and children in the Indianapolis area. He is board certified by the American Board of Podiatric Surgery, and is a member of the American Podiatric Medical Association. He enjoys providing comprehensive foot health information to the online community to help the public better understand their feet. Visit his practice website for more information.