Ohio Admin. Code 5160-10-31 - DMEPOS: footwear and foot orthoses
(A) Orthopedic shoes.
(1)(2) Payment may be made
for an orthopedic shoe only if at least one of the following conditions is met:
(2)(3) Greater frequency
of shoe replacement may be allowed for recipients
individuals younger than eight years of age. Payment
for shoe replacement beyond an established frequency for
recipients
individuals younger than twenty-one years of age
requires
is subject
to prior authorization (PA).
(3)(4) No payment is made
for an orthopedic shoe that is to be worn over a prosthesis.
(4)(5)
Payment for a foot orthosis includes the acquisition (by casting or other
means) of the model on which the orthosis is constructed.
(1)
No particular
form or format is specified for the certification of medical
necessity.
(a) The shoe is an integral part of an
orthotic device (brace);
(b) The
shoe has been molded specifically for the recipient
individual;
(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
an individual 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
an
individual 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.
(B) Specialized non-orthopedic shoes. Payment
may be made for a specially constructed non-orthopedic shoe for
a recipient
an
individual 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
includes an attestation that all of the following
statements are true:
(a) The
recipient
individual has diabetes mellitus;
(b) The conditions of coverage are
met;
(c) The prescriber is treating
the recipient
individual for diabetes under a comprehensive plan of
care;
(d) Therapeutic footwear is
medically necessary for the recipient
individual because of diabetes; and
(e) All relevant information is documented in
the recipient's
individual's medical record.
(2) Therapeutic footwear
must
may be
prescribed only by a podiatrist, pedorthist, orthotist, prosthetist, or other
qualified practitioner who manages the recipient's
individual's diabetes.
(3) Therapeutic footwear
must
may be
fitted and dispensed only by a podiatrist,
pedorthist, orthotist, or prosthetist.
(4) Payment may be made for therapeutic
footwear (shoes, inserts, or shoe modifications) only if the
recipient
individual 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
individual 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
individual has a foot deformity that cannot be
accommodated by a depth shoe. The nature and severity of the deformity
must
is to 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
necessary modification. Separate payment may be made
for inserts if the provider confirms in writing that the
recipient
individual has appropriate footwear meeting the
industry definition of a depth or custom-molded shoe, into which the insert can
be placed.
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, 07/16/2018
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