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