The Durable Medical Equipment Regional Carriers (DMERC) are responsible for setting medical
policy concerning coverage requirements for therapeutic footwear. For a diabetic insert to be
covered by Medicare, present policy requires that it must be molded to the patient’s foot to the
degree necessary to achieve the total contact standard. To achieve total contact the device must
be molded to come up to the arch while the foot is in a relatively uncompensated position.
The position, length and height of the device’s arch must match that of the patient’s
uncompensated arch to achieve the clinical benefits of total contact.
Why Total Contact
Many dual density inserts provide the clinical benefits of cushioning the plantar surface of the foot.
Even the low cost devices sold in supermarkets provide some degree of cushioning. Medicare is
reimbursing for a higher level molded total contact device to achieve two additional clinical benefits.
The first is pressure equalization. By reaching up into the arch, the total contact device increases the
weight-bearing surface of the foot which redistributes the pressure more evenly across the plantar
surface. The next is reduction of shearing forces by maintaining the foot in a relatively fixed position,
minimizing horizontal and vertical foot movement. A covered device must achieve all three clinical
benefits, as opposed to just cushioning.
Prefabricated Inserts - Materials and Molding Characteristics
Many of the prefabricated devices on the market have polyurethane shells, (bottom layers) that
cannot be heat molded to match the shape and height of the patient’s arch. The only portion of
these devices that is heat moldable is a thin top layer of plastazote or EVA which is not thick
enough to achieve total contact with the arch for most patients. A molding block designed to
hold the foot in an uncompensated position, as the insert cools, has no effect because the
non-moldable shell will not retain the arch shape. The position, length and height of the
device’s arch does not match that of the patient’s uncompensated arch. The molded
device does not achieve total contact and, therefore, does not qualify as a covered service
(see SureFit Resource Publication on Medical Policy Requirements).
With SureFit custom molded inserts you can bill
the A5511 code informing Medicare that you are
providing a lab fabricated total contact device.
With SureFit’s custom molded inserts there is no doubt that every insert you
dispense meets Medicare’s requirement of total contact.
The physician, who submits the claim for diabetic inserts, not the manufacturer, is
responsible for demonstrating coverage under the Medicare benefit. The physician must
confirm the prefabricated devices ability to mold to the patient's foot and achieve total
contact on a per patient basis. What is the purpose of heating and molding the device
if the shape does not change?
