(1) "Orthopedic shoes" are shoes that are specially constructed to aid in the correction of a deformity of the muscular skeletal structure of the foot; and for the preservation and restoration of the function of the skeletal system of the foot.
(2) "Molded shoes" are orthopedic shoes that are directly molded of leather, plastic, or a similar material, to a patient model.
(3) "Mismated shoes" are one pair of orthopedic shoes in which one shoe is a whole size and/or width larger than the other.
(B) Covered services and limitations.
(1) Prior authorization is required before orthopedic shoes will be considered for payment. Prior authorization requests must contain a precise description of the shoe to be dispensed and must include the manufacturer and/or laboratory, style and size of the item.
(2) Orthopedic shoes are covered only if the shoe is an integral part of a brace with the following exceptions: molded, mismated, and club foot shoes or shoes for children under the age of eight, diagnosed as having a deformity or condition as listed in paragraph (C) of this rule.
(3) Shoe modifications or additions shall be covered if they are medically necessary and are prescribed by a physician (D.P.M., D.O. or M.D.), or an advanced practice nurse (APN) subject to the limitations as specified in appendix A to rule 5101:3-10-20 of the Administrative Code.
(4) Reimbursement for foot orthoses includes all casting and shall only be billed by the individual who performs the actual casting.
(5) For medicaid-eligible recipients age eight and older, a maximum of two pairs of shoes every three hundred sixty-five days shall be considered for payment.
(6) For children under the age of eight, to accommodate growth, a maximum of three pairs of shoes every three hundred sixty-five days shall be considered for payment.
(7) Depth inlay shoes are covered only if the shoe is an integral part of a brace.
(C) Orthopedic shoes, not attached to a brace, for children under the age of eight, will be covered only for the following diagnoses:
(1) Talipes equino varus (club foot).
(2) Metatarsus adductus.
(3) Femoral torsion.
(4) Tibial torsion.
(5) Vertical talus.
(6) Fracture (major bones).
(8) Post-surgical control.
(D) Non-coverage determination.
Orthopedic shoes are denied as non-covered if the shoe is put on over a partial foot prosthesis or other lower extremity prosthesis that is attached to the residual limb.
R.C. 119.032 review dates: 09/27/2006 and 01/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 5111.021
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 1/1/80, 3/1/84, 10/1/88, 2/17/91, 12/30/93 (Emer), 3/31/94