A5500, For diabetics only, fitting (including follow-up), custom preparation and
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Supplier must have received a signed Standard Written Order (SWO)/Written Order Prior to Delivery (WOPD) before delivering DMEPOS base items; the WOPD must list the base item and may list associated options/accessories/supplies.
- Supplier must maintain proof of delivery (POD) documentation in files and make it available to the Medicare contractor upon request.
- The nature and severity of a beneficiary's foot deformity must be well documented in the supplier's records and available upon request when providing custom-molded shoes.
- Suppliers must follow additional documentation/payment rules in the LCD-related Standard Documentation Requirements Article, LCD-related Policy Article, Supplier Manual, and DME MAC web bulletins.
Key Coverage Criteria
- Therapeutic shoes and related inserts are covered when the item is an eligible Medicare benefit category and is reasonable and necessary for diagnosis or treatment of illness/injury or to improve the functioning of a malformed body member.
- Therapeutic shoes are provided for persons with diabetes when the above Medicare coverage criteria are met.
- A custom-molded shoe (HCPCS A5501) is covered when the beneficiary has a foot deformity that cannot be accommodated by a depth shoe and the nature and severity of the deformity are documented.
- Separate inserts may be covered and dispensed independently if the supplier documents in writing that the beneficiary has appropriate footwear (depth shoes or custom-molded shoes) into which the insert can be placed.
- History of pre-ulcerative calluses of either foot;or
- History of previous foot ulceration of either foot;or
2 Active Policies
ANTHEM-CG-DME-19, CG-DME-19 Therapeutic Shoes, Inserts, or Modifications for Individuals with Diabetes
L33369, Therapeutic Shoes for Persons with Diabetes
Related Codes
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