Does Medicare Pay for SAS Shoes for Seniors? A Comprehensive Guide

According to the Centers for Disease Control and Prevention, more than 38 million Americans have diabetes, a condition that often leads to foot complications. For many, specialized footwear is a medical necessity, prompting the crucial question: Does Medicare pay for SAS shoes for seniors?

Quick Summary

Medicare may cover therapeutic footwear, potentially including certain SAS styles, for seniors with diabetes who meet specific eligibility criteria. Coverage is tied to medical necessity for treating foot complications, not brand-name shoes, and requires proper documentation from a doctor and a Medicare-enrolled supplier.

Key Points

• Not About the Brand: Medicare does not cover SAS shoes specifically by name; it covers therapeutic footwear for qualifying medical needs.

• Diabetes is Required: Eligibility for this benefit requires a documented diagnosis of diabetes.

• Qualifying Foot Conditions: You must have at least one specific diabetes-related foot condition, such as neuropathy, poor circulation, or a foot deformity, to qualify.

• Certifying Physician is Key: A primary care doctor or endocrinologist must certify your need and manage your diabetes care for the claim to be valid.

• Medicare-Enrolled Supplier is Crucial: You must purchase the shoes from a supplier who is enrolled in Medicare and accepts assignment for coverage.

• Annual Coverage Limit: Medicare provides coverage for one pair of extra-depth or custom-molded shoes and a certain number of inserts per calendar year.

Understanding the Medicare Diabetic Shoe Benefit

Medicare Part B (Medical Insurance) provides coverage for therapeutic shoes and inserts for people with diabetes. This benefit aims to prevent foot complications from diabetes, such as neuropathy, ulcers, and poor circulation. Coverage depends on meeting strict eligibility requirements and following a specific procedure.

The Core Requirements for Coverage

To qualify for Medicare-covered therapeutic shoes, including certain extra-depth styles, a senior must meet several key criteria:

• You must have Medicare Part B. Enrollment is essential as the benefit falls under Medicare's medical insurance.
• You must have a documented diabetes diagnosis and be under a comprehensive care plan managed by your doctor.
• You must have at least one qualifying diabetes-related foot condition. These include a history of amputation or ulceration, pre-ulcerative calluses, peripheral neuropathy with calluses, foot deformity, or poor circulation in either foot.
• You must use a Medicare-enrolled supplier. The shoes and inserts must be provided and fitted by a qualified supplier enrolled in Medicare who accepts assignment.

The Step-by-Step Process for Obtaining Coverage

1. See your diabetes-managing doctor. They must certify your diabetes diagnosis, care plan, and need for therapeutic shoes.
2. Get a prescription from a qualified foot specialist. A podiatrist, orthotist, or pedorthist must examine your feet, document your condition, and write a prescription for the shoes and inserts.
3. Find a Medicare-enrolled supplier. Use the official Medicare supplier directory or ask your foot specialist for recommendations. Ensure the provider is enrolled in Medicare and accepts assignment.
4. Visit the supplier for fitting. The supplier will fit the shoes and inserts and document the process.
5. Submit the claim. Your supplier typically handles claim submission to Medicare, including all necessary doctor documentation.

Can a Specific Brand like SAS be Covered?

Medicare covers therapeutic footwear based on whether the shoe meets specific requirements (often referred to by billing code A5500), not by brand name.

• Some SAS shoe styles meet Medicare's standards for therapeutic footwear, featuring extra depth, seamless interiors, and specialized inserts.
• If a specific SAS model qualifies as therapeutic footwear and meets all medical necessity and documentation criteria, it can be covered.
• You must purchase these shoes from a Medicare-enrolled supplier who accepts assignment, not a standard retail store, for coverage.

Medicare Coverage Comparison: Extra-Depth vs. Custom-Molded Shoes

Feature	Extra-Depth Shoes	Custom-Molded Shoes
Coverage	One pair per calendar year	One pair per calendar year
Inserts	Three pairs of custom-molded inserts annually	Two additional pairs of inserts annually
Qualifying Condition	Documented diabetes + foot conditions like neuropathy with callus formation, deformity, etc.	Medically necessary for severe foot deformities not accommodated by extra-depth shoes.
Process	Requires prescription and fitting by Medicare-enrolled provider	More specialized process, often involving a cast or digital scan.
Cost Share	20% coinsurance after Part B deductible	20% coinsurance after Part B deductible.

Potential Reasons for Coverage Denial

Understanding common issues can help. Reasons for denial include:

• Incomplete or Missing Documentation: Improper or outdated paperwork and missing signatures.
• Incorrect Supplier: Purchasing from a supplier not enrolled in Medicare or not accepting assignment.
• Expired Prescription or Certification: Documentation must be current.
• Non-Qualifying Condition: Your documentation must specify a qualifying diabetic foot condition.

Conclusion

Medicare covers therapeutic footwear for seniors with diabetes who meet specific medical criteria and follow the correct documentation process, rather than covering SAS shoes by brand name. Many SAS styles do qualify as therapeutic footwear. To ensure coverage, you need a diabetes diagnosis and related foot condition, certification from your diabetes doctor, a prescription from a foot specialist, and you must use a Medicare-enrolled supplier who accepts assignment.

For more information on Medicare's coverage for therapeutic footwear, visit the official Medicare website.

With the correct steps and documentation, a covered pair of therapeutic SAS shoes can significantly benefit foot health and mobility.

Frequently Asked Questions

Will Medicare cover 100% of the cost for SAS shoes?

No, Medicare does not cover 100% of the cost. For beneficiaries in Original Medicare, Part B pays 80% of the Medicare-approved amount after the annual deductible is met. The remaining 20% is your coinsurance.

What documentation do I need to get Medicare to pay for SAS shoes?

You need two main documents: a Certification of Medical Necessity from the doctor managing your diabetes and a prescription from a qualified foot specialist, like a podiatrist. The specialist must also document your qualifying foot condition.

Can I buy SAS shoes from any store and submit a claim to Medicare?

No, you must buy the therapeutic shoes from a Medicare-enrolled supplier who accepts assignment. If you purchase from a non-participating store, your claim will be denied, and you will be responsible for the full cost.

Are there other qualifying foot conditions besides diabetes?

Medicare's specific therapeutic shoe benefit is for individuals with diabetes who have qualifying foot conditions. For orthopedic shoes due to other conditions, like severe arthritis, different Medicare rules or benefits might apply.

How often does Medicare pay for therapeutic shoes?

Medicare covers one pair of therapeutic shoes per calendar year, as long as you continue to meet the qualifying medical criteria. The benefit resets annually.

What is the difference between extra-depth and custom-molded shoes?

Extra-depth shoes have additional space for inserts and are the most common coverage option. Custom-molded shoes are individually crafted from a cast or scan of your foot and are covered for severe foot deformities that extra-depth shoes cannot accommodate.

What happens if my claim for SAS shoes is denied by Medicare?

If your claim is denied, you can appeal the decision. Common reasons for denial include incomplete paperwork or using a non-approved supplier. You should review the denial reason and work with your supplier and doctors to correct any issues for resubmission.