Unless otherwise specified, the licensing of persons authorized to fit or dispense therapeutic footwear for consumers with diabetes is administered and enforced by Chapter 4779. of the Revised Code. Any provider seeking reimbursement for therapeutic footwear must meet the provisions contained within this rule when applicable in order to be eligible for reimbursement for services provided.
(A) Coverage determination
For a consumer to be eligible for therapeutic footwear the following criteria must be met:
(1) The consumer has diabetes mellitus ("International Classification of Diseases, Ninth Revision" (ICD-9) diagnosis codes 250.00 - 250.93 ); and
(2) The consumer has one or more of the following conditions:
(a) Previous amputation of the other foot, or part of either foot;
(b) History of previous foot ulceration of either foot;
(c) History of pre-ulcerative calluses on either foot;
(d) Peripheral neuropathy with evidence of callus formation of either foot;
(e) Foot deformity of either foot; or
(f) Poor circulation in either foot; and
(3) The certifying prescriber who is managing the consumer's systemic diabetes condition has certified that the indications in paragraphs (A)(1) and (A)(2) of this rule are met and that he or she is treating the consumer under a comprehensive plan of care for his or her diabetes and that the consumer needs therapeutic footwear.
(B) Non-coverage determination
(1) Items represented by code A5510 refer to inserts that are compression molded to the consumer's foot over time through the heat and pressure generated by wearing a shoe with the insert present. Since these inserts are not considered total contact at the time of dispensing, they do not meet the requirements of the benefit category and will be denied as noncovered.
(2) Inserts used in noncovered shoes are noncovered.
(3) Deluxe features of diabetic shoes (A5508) are noncovered.
(4) Shoes, inserts and/or modifications that are provided to patients who do not meet the coverage criteria are noncovered.
(1) The following documentation must be submitted for prior authorization (PA) before reimbursement for therapeutic footwear will be considered in accordance with the provisions set forth in rule 5101:3-10-31 of the Administrative Code :
(a) Documentation to establish medical necessity of the requested item or service; and
(b) Any other documentation as required or requested by ODJFS for certain specific medical supplier services, as detailed in Chapter 5101:3-10 of the Administrative Code.
(2) Documentation for the prior authorization of therapeutic footwear must be submitted with the appropriate healthcare common procedure coding system (HCPCS) codes .
(1) The particular type of footwear that is necessary must be prescribed by a podiatrist or other qualified prescriber knowledgeable in the fitting of therapeutic footwear. The footwear must be fitted and dispensed by a podiatrist, pedorthist, orthotist, or prosthetist meeting the qualifications specified in Chapter 4779. of the Revised Code. Documentation that the provider is authorized to fit and dispense therapeutic footwear pursuant to Chapter 4779. of the Revised Code must be kept in the provider's records.
(2) The certifying prescriber (i.e., the prescriber who manages the systemic diabetic condition) may not furnish the footwear unless he or she practices in a defined rural area or a defined health professional shortage area.
(3) Separate inserts may be covered and dispensed independently of diabetic shoes if the provider of the shoes verifies in writing that the consumer has appropriate footwear into which the insert can be placed. This footwear must meet the industry definition for a depth or custom-molded shoe.
(4) A custom molded shoe (A5501) is covered when the consumer has a foot deformity that cannot be accommodated by a depth shoe. The nature and severity of the deformity must be well documented in the provider's records and such records may be requested by the Ohio department of job and family services (ODJFS) for review. If there is insufficient justification for a custom molded shoe but the general coverage criteria are met, reimbursement for services will be based on the allowance for the least costly medically appropriate alternative (A5500).
(1) There is no separate reimbursement for the fitting of shoes, inserts or modifications or for the certification of need or prescription of the footwear.
(2) Therapeutic footwear is reimbursed according to the ODJFS fee schedule contained in appendix DD to rule 5101:3-1-60 of the Administrative Code, or the provider's usual and customary charge, whichever is less.
R.C. 119.032 review dates: 09/20/2010 and 08/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 5111.021
Prior Effective Dates: 10/15/2006