Ohio Admin. Code 5160-10-31 - DMEPOS: footwear and foot orthoses
(A)
Orthopedic
shoes.
(1)
Payment may be made for an orthopedic shoe only if at least
one of the following conditions is met:
(a)
The shoe is an
integral part of an orthotic device (brace);
(b)
The shoe has been
molded specifically for the recipient;
(c)
The shoe is one
of a mismated pair;
(d)
The shoe is used to treat talipes equino varus (club
foot);
(e)
For a recipient younger than eight years of age, the
shoe is used independently of an orthotic device for one of the following
purposes:
(i)
Treatment of metatarsus adductus, femoral torsion, tibial
torsion, vertical talus, fracture of a major bone, or osteochondrosis;
or
(ii)
Post-surgical control;
(f)
For a recipient
eight years of age or older, the shoe is used for treatment of moderate or
severe peripheral neuropathy or peripheral arterial disease; or
(g)
A
modification or addition to the shoe is medically necessary and has been
prescribed by a physician, an advanced practice registered nurse, or a
physician assistant.
(2)
Greater frequency
of shoe replacement may be allowed for recipients younger than eight years of
age. Payment for shoe replacement beyond an established frequency for
recipients younger than twenty-one years of age requires prior authorization
(PA).
(3)
No payment is made for an orthopedic shoe that is to be
worn over a prosthesis.
(4)
Payment for a foot orthosis includes the acquisition
(by casting or other means) of the model on which the orthosis is
constructed.
(B)
Specialized non-orthopedic shoes. Payment may be made
for a specially constructed non-orthopedic shoe for a recipient younger than
twenty-one years of age only if both of the following conditions are met:
(1)
The shoe is to be
worn over an orthotic device; and
(2)
Commercially
available shoes that fit over the orthotic device would be unacceptably long or
otherwise ill-suited to ambulation.
(C)
Therapeutic
footwear for individuals with diabetes.
(1)
The default
certificate of medical necessity (CMN) form is the ODM 01912, "Certificate of
Medical Necessity: Therapeutic Footwear for Individuals with Diabetes" (rev.
7/2018). The CMN must include an attestation that all of the following
statements are true:
(a)
The recipient has diabetes mellitus;
(b)
The conditions of
coverage are met;
(c)
The prescriber is treating the recipient for diabetes
under a comprehensive plan of care;
(d)
Therapeutic
footwear is medically necessary for the recipient because of diabetes;
and
(e)
All relevant information is documented in the
recipient's medical record.
(2)
Therapeutic
footwear must be prescribed by a podiatrist or other qualified practitioner who
manages the recipient's diabetes.
(3)
Therapeutic
footwear must be fitted and dispensed by a podiatrist, pedorthist, orthotist,
or prosthetist.
(4)
Payment may be made for therapeutic footwear (shoes,
inserts, or shoe modifications) only if the recipient has diabetes mellitus and
at least one of the following conditions is met:
(a)
Either an entire
foot or part of either foot has been amputated; or
(b)
In either foot,
the recipient has a history of ulceration, pre-ulcerative calluses, peripheral
neuropathy with evidence of callus formation, foot deformity, or poor
circulation.
(5)
Payment may be made for a custom-molded shoe only if
the recipient has a foot deformity that cannot be accommodated by a depth shoe.
The nature and severity of the deformity must be well documented in the
provider's records. If there is insufficient evidence of need for a
custom-molded shoe, then payment will be limited to the cost of the least
expensive medically appropriate alternative.
(6)
No payment is
made for the following items:
(a)
Inserts that are compression-molded to the foot over
time by the heat and pressure of being worn inside a shoe;
(b)
Inserts used in
noncovered shoes; and
(c)
Deluxe features.
(7)
Payment for a
therapeutic shoe includes fitting, necessary inserts, and any required
modification. Separate payment may be made for inserts if the provider confirms
in writing that the recipient has appropriate footwear meeting the industry
definition of a depth or custom-molded shoe, into which the insert can be
placed.
Replaces: 5160-10-12, 5160-10-31
Notes
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 04/07/1977, 12/21/1977, 12/30/1977, 01/01/1980, 03/01/1984, 10/01/1988, 02/17/1991, 12/30/1993 (Emer), 03/31/1994, 10/15/2006, 01/01/2007, 08/02/2011
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