Medicare Pays for One Pair of Diabetic Shoes a Year, but Missing Records Caused Most Improper Payments

Medicare’s diabetic shoe benefit can sound like welcome relief, but diabetes by itself is not enough to get a pair covered.

Take Carol, a 68-year-old retired bookkeeper with type 2 diabetes and Original Medicare. After a neighbor tells her about the benefit, she gets fitted for extra-depth shoes and inserts and expects Medicare to cover part of the cost. Instead, the claim is denied and the supplier bills her.

Quick Read

• To qualify for Medicare’s diabetic shoe benefit, a person must have diabetes and a documented foot condition such as ulcers, deformity, or poor circulation. Diabetes alone does not qualify someone, and it does not rule them out either.

• Inadequate paperwork was behind 85.5% of improper diabetic shoe payments, and the diabetes doctor must certify the need within the required time frames before delivery.

• Medicare covers one pair of extra-depth shoes plus three pairs of inserts each year, and the patient pays 20% of the approved amount only when the supplier accepts assignment.

The paperwork matters as much as the fitting. The Centers for Medicare & Medicaid Services says insufficient documentation accounted for 85.5% of improper payments for diabetic shoes in the 2024 reporting period. To qualify, Carol needs a specific foot problem in addition to diabetes, along with medical records and a certification that satisfy Medicare’s rules.

Diabetes Is Only the Starting Point

Medicare.gov says therapeutic shoes and inserts require two medical conditions. The person must have diabetes, and must also have severe diabetes-related foot disease. If the feet are otherwise healthy, the benefit does not apply.

CMS says the following foot problems can count if the doctor documents at least one of them:

• Previous amputation of the other foot, or part of either foot

• History of foot ulcer

• History of pre-ulcerative calluses

• Peripheral neuropathy with evidence of callus formation

• Foot deformity

• Poor circulation

If Carol’s feet are numb but her chart does not show calluses, neuropathy alone would not meet the standard. She would need one of the other qualifying conditions. The doctor managing her diabetes has to document the qualifying problem, or review and sign off on another qualified clinician’s findings, before certifying her need for shoes.

Her Diabetes Doctor Must Certify the Need

The second requirement concerns the signer. The doctor managing Carol’s diabetes must certify three things: that she meets the standard, that she is under a comprehensive diabetes care plan, and that she needs the shoes.

CMS also sets deadline rules. The doctor must see her in person for diabetes care within 6 months before the shoes are delivered. The certification statement must be signed within 3 months before delivery. A visit from many months earlier may no longer count by the time she is fitted later.

A podiatrist or another qualified clinician writes the prescription. That can include a nurse practitioner or physician assistant, and the diabetes doctor may write it as well. The clinicians and the supplier must be enrolled in Medicare. Enrollment and accepting Medicare’s approved amount are separate issues, so Carol should confirm both.

What One Pair a Year Covers

Once she qualifies, Medicare pays for one of the following each calendar year, depending on her needs:

• One pair of extra-depth shoes plus three pairs of inserts

• One pair of custom-molded shoes, including inserts, plus two additional pairs of inserts, if a deformity keeps her from wearing extra-depth shoes

Her share follows the usual Part B cost-sharing rules. After she meets the annual Part B deductible, she pays 20% of Medicare’s approved amount if the supplier accepts assignment. If the supplier does not accept assignment, it can bill any amount, and she is responsible for anything above Medicare’s approved rate.

Documentation Is the Main Pitfall

A signed certification is not enough by itself. The medical record must support it, including the foot condition that makes her eligible. A checked box cannot replace exam notes.

These three steps can help protect her next claim:

1. Check whether her records show a qualifying foot condition. If a podiatrist or another clinician examined her feet, make sure those notes are sent to the diabetes doctor for review and approval.

2. Confirm that the clinicians and the supplier are enrolled in Medicare. Ask whether the supplier accepts assignment, meaning it agrees to Medicare’s approved rate.

3. Count backward from the delivery date. The diabetes visit and foot exam must fall within the prior 6 months. The certification must follow the required visits and record review and be signed within the prior 3 months. Ask the supplier to verify the dates before delivery.

If Medicare has already denied the claim, Carol should check her Medicare Summary Notice for the reason, the amount she may owe, and appeal instructions. A denial does not automatically make her responsible for the supplier’s full bill. She should ask the supplier to review what it submitted and gather the medical records that support the claim without missing the appeal deadline.

Medicare’s shoe benefit begins with diabetes, but payment depends on the feet meeting the medical standard and the paperwork proving it, with every signature dated within the required window. For Carol, the chart work comes before the fitting.