Orthotics is a medical specialty that focuses on making and fitting medical devices that align, support, or alleviate orthopedic problems.
Medicare does cover orthotics in some cases if you meet your plan qualifications and other specific requirements.
Orthotic devices may provide support and pain relief for people experiencing foot problems like pain, osteoarthritis, spinal injury, back pain, or other orthopedic conditions.
Many physicians prescribe orthotics to help heal after surgeries like hip or knee replacement or injuries like whiplash. Orthotics are also used to relieve pain by keeping a limb stationary and stable. They are also used to provide extra support for muscles or joints that are either weak or deformed.
Spinal orthotics include back and neck braces to stabilize the jaw, neck, all regions of the back, and the spine.
Orthotics can support an entire leg and foot for proper alignment or when a slight difference in leg length causes awkwardness or a loss of balance.
Podiatrists may prescribe foot orthotics to treat foot conditions caused by arthritis, diabetic foot ulcers, plantar fasciitis, bunions, bursitis, tendinitis, or arch or heel pain.
There are three different types of orthotics.
Over-the-counter orthotics can be purchased off the shelf at any drug store. You can take them home and cut or customize them to fit in your shoe.
Some drug stores have a kiosk-generated orthotics machine that lets you stand on a pad that measures your foot size, weight distribution, and arch. From these measurements, the kiosk will recommend the best brand and size for you.
An orthopedic specialist dispenses prescription orthotics. The doctor will take an impression of your foot and order a custom orthotic or custom shoe after considering your medical conditions, height, weight, specific foot issues, foot flexibility, and more. The more severe your foot condition, the more likely you will need a prescription orthotic.
Several types of orthotics prescribed by doctors are covered under Medicare's durable medical equipment (DME) benefit. This includes:
For coverage to apply, your doctor (a podiatrist, orthotist, prosthetist, pedorthist, or another qualified individual) must determine that the orthotics are medically necessary and prescribe them as part of your treatment plan.
Also, DME suppliers must be enrolled and participate in Medicare.
Here are several specific examples of when Medicare will cover orthotics:
Diabetic conditions include poor circulation or neuropathy. Medicare Part B may cover the fit and cost of one pair of custom-fitted orthopedic shoes, two additional pairs of inserts for custom-molded shoes, or one pair of extra-depth shoes and three pairs of inserts each year for those patients. Medicare also covers shoe modifications instead of inserts.
Hip braces are often prescribed as part of hip replacement surgery. However, hip braces often do not include a foot orthotic device. Medicare may help pay for the hip brace, but coverage may not include an orthotic device.
Plantar fasciitis is a self-treatable foot ailment involving inflamed tissue on the bottom of the foot. It can usually be treated with physical therapy, shoe inserts, steroid injections, and surgery. If your doctor can prove that it is medically necessary and the prescription is required, you may be able to get Medicare coverage.
Also, over-the-counter benefits may be offered with some Medicare Advantage plans. So, even though you may not qualify for prescription orthotic coverage, you may be able to get coverage for OTC products at your local drug store or through a mail-order pharmacy.
Medicare may cover orthotic-related non-emergency medical transportation in an ambulance if you have a doctor's note detailing why an ambulance is medically necessary. However, to get this type of coverage, you may need to purchase a Medicare Advantage plan with a benefit that includes transportation to doctor's appointments, the hospital, and the pharmacy.
In some cases, Medicare may cover orthotics related to weight loss. Orthotics are often prescribed to ease the stress on the feet of some overweight people.
Medicare will cover orthotics related to a person who suffers from Morton's Neuroma. This condition is characterized by irritation of nerves in the toe, which often leads to numbness. Treatment usually includes using a metatarsal pad, cortisone injections, and surgery in some cases.
Bunions are covered by Medicare. Pain and stiffness symptoms usually get worse over time. Podiatrists will treat bunions by prescribing bunion pads, toe spacers, or shoe inserts. Surgery is sometimes prescribed as well.
Medicare covers stress fractures, which are small bone breaks often caused by repeated blows to an area and common when playing sports, running, or frequent jumping. Most stress fractures heal on their own, but sometimes a walking boot is required, and with more complex fractures, surgery may be necessary.
Peripheral Neuropathy occurs when damaged nerves cannot send proper messages to the rest of the body. This results in pain, numbness, burning sensations, tingling, and weakness. It can be caused by diabetes, exposure to toxins, infections, autoimmune conditions, neurological disorders, chronic alcoholism, and more. Medicare may cover orthotics for this condition, but peripheral neuropathy is usually treated with topical creams, prescription drugs, and synthetic nerve blockers.
Medicare does not cover routine podiatry services because they are not considered medically necessary. Some of those services include trimming toenails, removing corns and calluses, treating flattened arches, and foot cleaning and soaking.
There may be some isolated instances when these would be considered medically necessary, such as if a person has diabetes or peripheral neuropathy. It is best to discuss these specific conditions with your doctor to confirm whether Medicare coverage is provided or not.
Medicare considers orthotic devices as durable medical equipment (DME). This means Medicare Part B would cover 80% of the approved costs when recommended by a provider.
Patients who have Medicare Part B will have to pay 20% of the Medicare-approved cost AND any Part B deductible that may be required. In 2021, the standard Part B deductible is $203 per year.
Medicare considers DME to be used for medical reasons in the home, has a life expectancy of more than three years, and is not useful to anyone who is not sick or injured.
The provider must deem the orthotic as medically necessary to support recovery or avoid further complications, and it must be prescribed as part of an overall treatment plan. Devices can be pre-made or custom-made, depending on the patient's needs.
The other key to coverage is that the supplier of the orthotic device must be enrolled in Medicare and must accept Medicare assignment.
Keep in mind your doctor may recommend services or orthotics more often than Medicare covers or suggest services not covered by Medicare. If that happens, you could be stuck paying for all the costs on your own. It is best to discuss coverage in advance with your healthcare professional and the orthotic provider.
A Part C Medicare Advantage Plan or a Medicare Supplement plan may cover podiatry and orthotic costs not covered by Original Medicare. If this is important to you, consider discussing this when shopping for one of these policies.
DISCLAIMER: Information is for educational purposes only and should not be construed as an offer of insurance, advice, or recommendation. The information provided is not intended as tax, financial, investment, or legal advice. Please consult legal or tax professionals for specific information regarding your individual situation.
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