Medicare Advantage

Medical Policy

Title:

Orthopedic Footwear

Policy #:

MA05.012c

Policy

This policy uses coverage criteria developed solely based on applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents.

MEDICALLY NECESSARY

PROSTHETIC SHOES
Prosthetic shoes (L3250) are considered medically necessary and, therefore, covered, when they are considered an integral part of a prosthesis for an individual with a partial foot amputation, and both of the following indications are met:

The shoe is custom fabricated from a model of the individual
The shoe has a removable custom fabricated insert designed for a toe or distal partial foot amputation

OTHER SHOES AND FOOTWEAR
Other types of shoes (e.g., oxford shoes, high top, depth inlay or custom for nondiabetics) are considered medically necessary and, therefore, covered if they are an integral part of a covered leg brace as described by codes L1900, L1920, L1980-L2030, L2050, L2060, L2080, L2090, L3224, L3225, and L3649, and medically necessary for the proper functioning of the brace.

Heel replacements (L3455, L3460), sole replacements (L3530, L3540), and shoe transfers (L3600-L3640) involving shoes on a covered brace are considered medically necessary and, therefore, covered.

Inserts and other shoe modifications (L3000-L3170, L3300-L3450, L3465-L3520, L3550-L3595) are considered medically necessary and, therefore, covered if they are on a shoe that is an integral part of a covered brace, and if they are medically necessary, for the proper functioning of the brace.

NOT COVERED

A matching shoe that is not attached to a brace, including items related to that shoe, are not covered by the Company because it is an item not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

Shoes that are incorporated into a brace must be billed by the same supplier billing for the brace. Shoes that are billed separately (i.e., not as part of a brace) are not covered by the Company because it is an item not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

Shoes that are placed over a partial foot prosthesis or other lower extremity prosthesis (L5010-L5600), which is attached to the residual limb by other mechanisms (not part of a covered brace), are not covered by the Company because these are items not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

A foot pressure off-loading/supportive device (A9283) is not covered by the Company, and, therefore, not eligible for reimbursement consideration, because it is an item not covered by Medicare as it does not meet the definition of:

A therapeutic shoe for diabetics or related insert or modification
An orthopedic shoe or modification
A walking boot

The orthopedic footwear described by codes L3215, L3216, L3217, L3219, L3221, L3222 are not covered by the Company because these items are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include, but are not limited to, records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

STANDARD WRITTEN ORDER REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY REQUIREMENTS
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES (WHEN APPLICABLE)
The supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately 7 days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately 5 days before the individual would exhaust their on-hand supply.

For specified durable medical equipment (DME) items, documentation of a face-to-face encounter between the treating professional provider and the individual meeting the above requirements, including an assessment of the individual’s clinical condition supporting the need for the prescribed DME item(s), must be provided to and kept on file by the DME supplier.

If required documentation is not available on file to support a claim at the time of an audit or record request, the supplier may be required to reimburse the Company for overpayments.

Guidelines

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, orthopedic footwear are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not covered are not eligible for coverage or reimbursement by the Company.

Description

A prosthetic shoe (a device used when all or a substantial portion of the front part of the foot is missing) can be covered as a terminal device; i.e., a structural supplement replacing a totally or substantially absent hand or foot. The function of the prosthetic shoe is quite distinct from that of excluded orthopedic shoe and supportive foot devices that are used by individuals whose feet, although impaired, are essentially intact.

References

Centers for Medicare & Medicaid Services (CMS). Federal Register. Medicare Program; Updates to Face-to-Face Encounter and Written Order Prior to Delivery List [Federal Register Web site]. 01/17/2023. Available at:

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/DMEPOS/Downloads/FINAL-RULE-MASTER-LIST-of-DMEPOS-Subject-to-Frequent-Unnecessary-Utilization-2018-03-30.pdf . Accessed December 11, 2025.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15: Covered medical and other health Services. §120: Prosthetic Devices [CMS Web site]. 12/21/2023. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf. Accessed December 11, 2025.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 280.10: Prosthetic shoe. [CMS Web site.] Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=208&ncdver=1&bc=AgAAQAAAAAAAAA==&. Accessed December 11, 2025.

Centers for Medicare & Medicaid Services (CMS). Master List of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Items Potentially Subject to Conditions of Payment. [CMS Web site]. Original 11/08/2019. (Revised 04/13/2022). Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Master-List. Accessed December 11, 2025.

Centers for Medicare & Medicaid Services (CMS). Required Face-To-Face Encounter and Written Order Prior To Delivery List. [CMS Web site]. Effective date: 08/12/2024. Available at: https://www.cms.gov/files/document/required-face-face-encounter-and-written-order-prior-delivery-list.pdf . Accessed December 11, 2025.

Noridian Healthcare Solutions. Local Coverage Determination (L33641): Orthopedic Footwear. [Noridian Healthcare Solutions Web Site]. Original Date 10/01/2015. (Revised 01/01/2020). Available at:
https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33641. Accessed December 11, 2025.

Noridian Healthcare Solutions. Local Coverage Article (A52481): Orthopedic Footwear. [Noridian Healthcare Solutions Web Site]. Original Date 10/01/2015. (Revised 11/01/2023). Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52481. Accessed December 11, 2025.

Noridian Healthcare Solutions. Local Coverage Article (A55426): Standard Documentation Requirements for All Claims Submitted to DME MACs. [Noridian Healthcare Solutions Web Site]. Original Date 01/01/2017. (Revised 01/01/2024). Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=55426. Accessed December 11, 2025.

Noridian Healthcare Solutions. Noncovered Items. [Noridian Healthcare Solutions Web site]. Last Updated December 9, 2023. Available at:https://med.noridianmedicare.com/web/jadme/topics/noncovered-items. Accessed December 11, 2025.

Coding

CPT Procedure Code Number(s)

N/A

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

See Attachment B.

HCPCS Level II Code Number(s)

See Attachment A.

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA05.012c:

03/04/2026	The policy has been reviewed and reissued to communicate the Company’s continuing position on orthopedic footwear.
04/02/2025	This policy has been reissued in accordance with the Company's annual review process.
03/06/2024	The policy has been reviewed and reissued to communicate the Company’s continuing position on Orthopedic Footwear.
01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
04/17/2023	This version of the policy will become effective 04/17/2023. In accordance with Medicare, Face-to-Face Requirement language has been removed per 2023 CMS New Final Rule. Coding Table is consistent with current CMS guidelines.

Revisions From MA05.012b:

06/06/2022

This version of the policy will become effective 06/06/2022.

In accordance with Medicare, Face-to-Face Requirement language has been added for HCPCS code L3330: Lift, elevation, metal extension (skate), and documentation requirements per CMS New Final Rule.

Revisions From MA05.012a:

04/07/2021	The policy has been reviewed and reissued to communicate the Company's continuing position on Orthopedic Footwear.
02/12/2020	This policy has been reissued in accordance with the Company's annual review process.
06/05/2019	The policy has been reviewed and reissued to communicate the Company’s continuing position on Orthopedic Footwear.
10/24/2018	This policy has been reissued in accordance with the Company's annual review process.
06/21/2017	The policy has been reviewed and reissued to communicate the Company’s continuing position on Orthopedic Footwear.
08/31/2016	The policy has been reviewed and reissued to communicate the Company’s continuing position on Orthopedic Footwear.
11/06/2015	This version of the policy will become effective 11/06/2015. The policy statement has been revised to include the following criteria: Prosthetic shoes (L3250) are considered medically necessary when an integral part of a prosthesis for an individual with a partial foot amputation. Existing durable medical equipment documentation requirements, in accordance with Medicare, are now included with examples.

Revisions From MA05.012:

01/01/2015

This is a new policy.

Version Effective Date:

1/1/2024

Version Issued Date: