Referring Patients for Shoes & Inserts

If a patient has Medicare Part B or a Medicare Managed plan, such as Blue Cross Medicare Advantage or Tufts Medicare Preferred, they 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. These Notes can be faxed to our West Springfield or Bloomfield office and must be on file prior to scheduling an appointment. 
  • This same physician must complete the Medicare CMN and Addendum to clinical notes. These two forms can be found on the right hand side of this webpage.
• The actual prescription can be written by the patient’s primary care physician, endocrinologist, OR another medical professional. Other professionals could include a Doctor of Podiatric Medicine (DPM), 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 a patient has a MassHealth plan that covers orthotic and prosthetic services, they 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:

• A doctors prescription.
• A copy of the MassHealth CMN for diabetics completed by an MD or DO physician (this form can be found on the right hand side of this webpage).

Unlike Medicare, MassHealth will cover custom foot orthotics, and shoe modifications such as lifts and rocker bottoms for non diabetic patients if they have the following:

• A doctors prescription, this can come from an MD, DO, NP, PAC or a DPM.
• The MassHealth Non Diabetic CMN completed by the same physician (this form can be found on the right hand side of this webpage).

*MassHealth Primary Care Clinician Plans (PCC) require a referral from the primary care physician. Our NPI# is 1558376913, please submit a referral request through the MMIS portal.

If a patient has Medicare Part B or a Medicare Managed plan, such as Blue Cross Medicare Advantage or Tufts Medicare Preferred, and MassHealth secondary they 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. These Notes can be faxed to our West Springfield or Bloomfield office and must be on file prior to scheduling an appointment. 
  • This same physician must complete the Medicare CMN, Addendum to clinical notes and MassHealth Diabetic CMN. These three forms can be found on the right hand side of this webpage.
• The actual prescription can be written by the patient’s primary care physician, endocrinologist, podiatrist, OR another medical professional. Other professionals could include a Doctor of Podiatric Medicine (DPM), 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.

Commonwealth Care Alliance 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 clinician involved in the patients care.

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 clinician involved in the patients care.

BMC Healthnet 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.

Allways Health Partners requires a prescription and letter of medical necessity 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 clinician involved in the patients care.

All Blue Cross plans require a doctor’s prescription, some also require a letter of medical necessity 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 the members plan type requires a letter of medical necessity please call us at (413)785-4047 or (860)904-2419.

Commercial Tufts Health Plans require 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 clinician involved in the patients care.

Tufts Medicare Preferred requires a prescription for diabetic shoes and inserts and all the same paperwork as Medicare Part B. The prescription can come from a primary care physician, podiatrist, endocrinologist, wound care physician, nurse practitioner, physicians assistant or any clinician involved in the patients care. The Medicare documentation  must still come from an MD or DO treating the diabetic condition.

Tufts Health Public Plans  require a prescription and letter of medical necessity 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 clinician involved in the patients care.

United Health Care and AARP require 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 clinician involved in the patients care.

Medicare Advantage & Senior Care Options Plans require a prescription for diabetic shoes and inserts and all the same paperwork as Medicare Part B. The prescription can come from a primary care physician, podiatrist, endocrinologist, wound care physician, nurse practitioner, physicians assistant or any clinician involved in the patients care. The Medicare documentation  must still come from an MD or DO treating the diabetic condition.

Cigna requires a prescription and letter of medical necessity 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 clinician involved in the patients care.

GIC/Unicare requires a prescription and letter of medical necessity 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 clinician involved in the patients care.

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

We also recommend patients call their insurance companies and ask about their Durable Medical Equipment benefits (DME for short). They should ask if they have a co-insurance, and if their deductible applies. They can also provide these possible codes to find out if they are deemed covered, A5500, A5501, A5512, A5513, and A5514.