Before Your Shoe/Foot Orthotics Visit

If you have Medicare Part B or a Medicare Managed plan, such as Blue Cross Medicare Advantage or Tufts Medicare Preferred, you will need to have the proper paperwork in order to qualify for diabetic footwear. Medicare allows one pair of diabetic shoes and up to three pairs of custom heat molded inserts per calendar year as long as the following criteria are met:

• The patient has diabetes and one of the following conditions:
  a. Foot deformity
  b. Current or previous foot ulceration
  c. Current or previous pre-ulcerative calluses
  d. Previous partial amputation of one or both feet, or complete amputation of one foot
  e. Poor circulation
• The patient must have an in-person visit with their primary care physician or endocrinologist with the credentials of MD or DO within six months of receiving diabetic shoes. At this visit it must be documented in the patient’s medical record that they have diabetes and at least one of the conditions mentioned above. The physician must also document any information relating to the patient’s diabetic management within the medical record and that the patient needs diabetic footwear. The following forms must be completed by your physician and forwarded to our office prior to your evaluation appointment:
  PDF Medicare CMN
  PDF Addendum to Medical Records
• The actual prescription can be written by the patient’s primary care physician, endocrinologist, podiatrist, OR another medical professional. Other professionals could include a physician assistant (PA), nurse practitioner (NP) or clinical nurse specialist (CNS). However, the documentation of need must still come from a certifying MD or DO.

If you have a MassHealth plan that covers orthotic and prosthetic services, you may be eligible for one pair of diabetic shoes and three pairs of custom heat molded inserts per year. In order to qualify, the following is required:

• Both the medical documentation AND the prescription must come from the primary care physician or endocrinologist with the credentials of MD or DO. Unlike Medicare, another professional CANNOT write the prescription.
• A copy of this form completed by the same MD or DO physician that writes your prescription:
  MassHealth CMN (pdf)

*Please remember: MassHealth Primary Care Clinician Plans (PCC) require a referral from your primary care physician. Please have your doctor’s office submit a referral through the MassHealth provider portal. Our NPI# is 1558376913

You must follow the rules for MassHealth requiring you to obtain medical documentation AND a prescription from your primary care physician or endocrinologist with the credentials of MD or DO. Therefore, the following must be completed:

• • In-person visit with your primary care physician or endocrinologist with the credentials of MD or DO within six months of receiving diabetic shoes.
  • MD or DO physician’s notes
  • Prescription from MD or DO physician
  • (PDF) MassHealth CMN
  • (PDF) Medicare CMN
  • (PDF) Addendum to Medical Records

Commonwealth Care Alliance only requires a prescription for diabetic shoes and inserts. The prescription can come from a primary care physician, podiatrist, endocrinologist, wound care physician, nurse practitioner, physicians assistant or any physician involved in the patients care.

Serenity Care PACE requires a prescription for diabetic shoes and inserts and a referral from Serenity Care PACE. The prescription can come from a primary care physician, podiatrist, endocrinologist, wound care physician, nurse practitioner, physicians assistant or any physician involved in the patients care.

*Please note that Serenity Care PACE must schedule the appointment on your behalf. Please call them directly to request an appointment with us.

Husky Plan requires a prescription for diabetic shoes and inserts. The prescription can come from a primary care physician, podiatrist, endocrinologist, wound care physician, nurse practitioner, physicians assistant or any physician involved in the patients care. Husky Plans that do cover shoes and inserts only cover 2 pairs of custom or heat molded inserts per year.

*We accept Plans A-D but some levels of coverage don’t cover Durable Medical Equipment, Prosthetics, or Orthotics. We can check your plan for you or you can also call Husky to verify if your plans covers these services.

BMC Healthnet requires a prescription for diabetic shoes and inserts and prior authorization for all Durable Medical Equipment. The prescription can come from a primary care physician, podiatrist, endocrinologist, wound care physician, nurse practitioner, physicians assistant or any physician involved in the patients care.

Allways Health Partners requires a prescription, letter of medical necessity, and prior authorization for all Durable Medical Equipment. This paperwork can come from a podiatrist, primary care physician, endocrinologist, nurse practitioner, physicians assistant or any other clinician involved in the patients care.

All Blue Cross plans require a doctor’s prescription. Some also require letters of medical necessity and prior authorization for diabetic shoes and inserts. This paperwork can come from a podiatrist, primary care physician, endocrinologist, nurse practitioner, physicians assistant or any other clinician involved in the patients care.

*If you would like to know if your plan type requires a letter of medical necessity please call us at (413)785-4047 or (860)904-2419.

*Blue Cross Medicare Advantage Plans follow the same Medicare paperwork requirements as Medicare Part B. You must have an in-person visit with an MD or DO that treats your diabetic condition within six months of receiving shoes. Please see Medicare Part B for more information.

*The Blue Cross Federal Employee Program does not cover diabetic shoes for any member. They will however cover diabetic inserts. Please call us for more information. 

We also recommend you contact Blue Cross directly to verify your Durable Medical Equipment benefits (DME for short). Ask them if you have a co-insurance amount, and if your deductible applies. You can also give them these possible codes to find out if they are deemed covered, A5500, A5501, A5512, A5513, and A5514.

All Tufts plans require a doctor’s prescription. Some also require letters of medical necessity and prior authorization for diabetic shoes and inserts. This paperwork can come from a podiatrist, primary care physician, endocrinologist, nurse practitioner, physicians assistant or any other clinician involved in your care.

*Tufts Medicare Preferred Plans follow the same Medicare paperwork requirements as Medicare Part B. You must have an in-person visit with an MD or DO that treats your diabetic condition within six months of receiving shoes. Please see Medicare Part B for more information.

*Tufts Public Plans (formally Network Health) require a prescription, letter of medical necessity and prior authorization for all Durable Medical Equipment.

We also recommend you contact Tufts directly to verify your Durable Medical Equipment benefits (DME for short). Ask them if you have a co-insurance amount, and if your deductible applies. You can also give them these possible codes to find out if they are deemed covered, A5500, A5501, A5512, A5513, and A5514.

Health New England Plans (including Medicare Advantage and Be Healthy) require a prescription for diabetic shoes and inserts and prior authorization for all Durable Medical Equipment. The prescription can come from a primary care physician, podiatrist, endocrinologist, wound care physician, nurse practitioner, physicians assistant or any physician involved in the patients care.

Please Note: Health New England provides us with limited benefit information. We highly recommend you contact Health new England directly to verify your Durable Medical Equipment benefits (DME for short). Ask them if you have a co-insurance amount, and if your deductible applies. You can also give them these possible codes to find out if they are deemed covered, A5500, A5501, A5512, A5513, and A5514.

All Cigna plans require a doctor’s prescription and a letter of medical necessity for diabetic shoes and inserts. Some plans also require prior authorization. This paperwork can come from a podiatrist, primary care physician, endocrinologist, nurse practitioner, physicians assistant or any other clinician involved in the patients care.

We also recommend you contact Cigna directly to verify your Durable Medical Equipment benefits (DME for short). Ask them if you have a co-insurance amount, and if your deductible applies. You can also give them these possible codes to find out if they are deemed covered, A5500, A5501, A5512, A5513, and A5514.

All GIC/Unicare plans require a doctor’s prescription and a letter of medical necessity for diabetic shoes and inserts. Some plans also require prior authorization. This paperwork can come from a podiatrist, primary care physician, endocrinologist, nurse practitioner, physicians assistant or any other clinician involved in the patients care.

We also recommend you contact GIC or Unicare directly to verify your Durable Medical Equipment benefits (DME for short). Ask them if you have a co-insurance amount, and if your deductible applies. You can also give them these possible codes to find out if they are deemed covered, A5500, A5501, A5512, A5513, and A5514.

We accept patients with Department of Veterans Affairs benefits. You’ll need an Orthotics/Prosthetics referral from your podiatrist or another physician at your VA Medical Center. The VA may ask for our contact information and our NPI# which is: 1558376913.

All commercial plans require a doctor’s prescription. Some also require letters of medical necessity and prior authorization for diabetic footwear. Please call us at 413-785-4047 for information about your insurance plan requirements.

You can also call your insurance company and ask about your Durable Medical Equipment benefits (DME for short). Ask them if you have a co-insurance amount, and if your deductible applies. You can also give them these possible codes to find out if they are deemed covered, A5500, A5501, A5512, A5513, and A5514.