DIABETIC (THERAPEUTIC) SHOES

Valid Physician Order/Statement of Medical Necessity that contains:

- Beneficiary’s name

- Physician’s name-must be an M.D. or D.O. Order cannot co-signed by an M.D./D.O.

- Date of the order and the start date, if start date is different from the date of the order

- Detailed description of item(s) to be dispensed including each separately billed component

- Treating physician’s signature, NPI, and signature date

OR

Completion of “Physician’s Order/Certificate of Medical Necessity for Diabetic Shoes and Insoles”form.

AND

Chart notes from the certifying physician (MUST be M.D. or D.O. and cannot be co-signed by M.D. or D.O.) documenting that the beneficiary meets the following criteria:

- Beneficiary has diabetes mellitus (ICD-9 codes 249.00-250.93);and Beneficiary has had a Face 2 Face office visit within six months of the shoe/insert delivery by the certifying physician documenting the beneficiary has one or more of the following conditions:

-Previous amputation of the other foot, or part of either foot,or

-History of previous foot ulceration of either foot,or

-History of pre-ulcerative calluses of either foot,or

- Peripheral neuropathy with evidence of callus formation of either foot,or

- Foot deformity of either foot,or

- Poor circulation in either foot