Medicare (CMS LCD/NCD) Diabetic Therapeutic Shoes & Inserts prior authorization requirements (2026)
What Medicare (CMS LCD/NCD) generally requires to approve Diabetic Therapeutic Shoes & Inserts (CPT A5500, A5501, A5512, A5513), for Medicare plans. Based on the cited policy, Medicare (CMS LCD/NCD) does not generally require prior authorization for Diabetic Therapeutic Shoes & Inserts (CPT A5500, A5501, A5512, A5513). Confirm with Medicare (CMS LCD/NCD), as this can vary by plan.
Medical-necessity criteria Medicare (CMS LCD/NCD) generally applies
Medicare covers one pair of therapeutic shoes (depth-inlay or custom-molded) and inserts per calendar year for a beneficiary with diabetes mellitus who, under a comprehensive plan of care for diabetes, has at least ONE qualifying foot condition: (1) previous amputation of the foot or part of the foot; (2) history of previous foot ulceration; (3) history of a pre-ulcerative callus; (4) peripheral neuropathy with evidence of callus formation; (5) foot deformity; or (6) poor circulation. The physician managing the diabetes must certify the need; the shoes/inserts must be prescribed by a podiatrist or other qualified provider and furnished by a qualified supplier. Annual allowance: one pair of depth shoes plus three pairs of inserts, OR one pair of custom-molded shoes (including one pair of inserts) plus two additional pairs of inserts.
Diagnoses that commonly support medical necessity
ICD-10-CM diagnoses frequently associated with medical necessity for Diabetic Therapeutic Shoes & Inserts. Confirm the covered diagnosis list against the current Medicare (CMS LCD/NCD) policy.
Commonly required documentation
- Signed certification statement from the physician managing the diabetes (within the required window)
- documentation of diabetes plus at least one qualifying foot condition
- in-person foot evaluation
- prescription from a podiatrist or qualified provider
- qualified supplier.
Sources & verification
- BindingCMS (Medicare).View
Binding = the payer's own policy. Proxy = a public, evidence-based clinical guideline the payer mirrors. Portal-only = the binding criteria are confirmed in the administrator's portal. Always confirm against the payer for the member's specific plan. Last verified 2026-06-16.
Frequently asked questions
Does Medicare (CMS LCD/NCD) require prior authorization for Diabetic Therapeutic Shoes & Inserts?
Based on the cited policy, Medicare (CMS LCD/NCD) does not generally require prior authorization for Diabetic Therapeutic Shoes & Inserts (CPT A5500, A5501, A5512, A5513). Confirm with Medicare (CMS LCD/NCD), as this can vary by plan.
What does Medicare (CMS LCD/NCD) require to approve Diabetic Therapeutic Shoes & Inserts?
Medicare covers one pair of therapeutic shoes (depth-inlay or custom-molded) and inserts per calendar year for a beneficiary with diabetes mellitus who, under a comprehensive plan of care for diabetes, has at least ONE qualifying foot condition: (1) previous amputation of the foot or part of the foot; (2) history of previous foot ulceration; (3) history of a pre-ulcerative callus; (4) peripheral n… Always confirm against the current Medicare (CMS LCD/NCD) policy.
How long does a Medicare (CMS LCD/NCD) prior authorization take?
Turnaround varies by plan and submission method. Check the Medicare (CMS LCD/NCD) portal for current timeframes.
Submitting Diabetic Therapeutic Shoes & Inserts to Medicare (CMS LCD/NCD)?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.