Insurance Companies and Medicare - Lymphedema Shoes

Do Insurance Companies Cover Therapeutic Shoes For Lymphedema?  How About Medicare?

It’s a question we get asked a lot. 

At the present time Medicare does not cover shoes specifically for lymphedema, however, some insurance companies may cover shoes for lymphedema, but it depends on the specific policy, insurance provider, and whether the shoes are considered medically necessary.

Coverage often falls under durable medical equipment (DME) or prosthetics/orthotics. The Pedors Classic MAX and the Pedors Super MAX in the 6E and 10E widths along with the Wrap Sandal and the Pedors Slides in the 6E and 10E width have been specifically designed to work therapeutically for patients living with lymphedema. 

How To Determine If You Might Have Coverage For Lymphedema Shoes

1. Check Your Insurance Policy

• Look for coverage of compression garments, orthotics, or therapeutic shoes. Shoes for lymphedema may fall into one of these categories.
• Some policies explicitly cover therapeutic shoes for conditions like diabetes and may also apply to lymphedema if prescribed by a doctor.

2. Get a Prescription

• A doctor's prescription or letter of medical necessity is often required. This document should detail the need for specialized footwear to manage lymphedema symptoms and improve mobility or prevent complications.

3. Medicare

• Medicare Part B may cover therapeutic shoes but primarily for people with diabetes. Lymphedema-related shoe coverage could be considered under custom orthotics or prosthetic devices if medically justified.

4. Medicaid

• Medicaid coverage varies by state but may include medically necessary footwear for conditions like lymphedema.

5. Private Insurance

• Many private insurance plans cover DME or custom orthotics. Contact your provider to confirm.

6. Specialized Programs

• Some nonprofits or assistance programs may help cover the cost of lymphedema-related footwear if insurance doesn’t.

Recommendations

• Contact your insurance company for clarification.
• Work with a lymphedema specialist or durable medical equipment provider familiar with insurance billing for such items.
• Retain documentation (e.g., prescriptions, diagnosis codes, and doctor's notes)

Sample Script For When Calling Your Insurer about shoes for Lymphedema

Here’s a sample script you can use to talk to your healthcare insurer about coverage for shoes related to lymphedema. Tailor it to your situation as needed:

Opening the Call:

You:
“Hello, my name is [Your Name], and I’m calling to inquire about my insurance policy. I have a medical condition called lymphedema, and my doctor has recommended specialized shoes as part of my treatment. I’d like to know if these are covered under my plan.”

Key Questions to Ask:

1. General Coverage for Lymphedema-Related Items:
   You:
   “Does my plan cover medical equipment or devices related to lymphedema management? Specifically, I’m asking about therapeutic or custom shoes.”
2. Requirements for Coverage:
   You:
   “If these shoes are covered, could you tell me the requirements? For example:
• Do I need a prescription or letter of medical necessity from my doctor?
• Are there specific providers or suppliers I must use?
• Is pre-authorization required?”
3. Cost and Reimbursement:
   You:
   “What portion of the cost will my insurance cover? Is there a co-pay or deductible? Additionally, if I purchase the shoes first, can I submit a claim for reimbursement?”
4. Clarification on Specific Codes:
   You:
   “Are there specific billing codes I should ask my doctor or supplier to use when submitting claims for lymphedema-related shoes?”
5. Other Benefits or Alternatives:
   You:
   “If these shoes are not covered under my current plan, are there other related benefits, such as custom orthotics or compression garments, that might help with my condition?”

Closing the Call:

You:
“Thank you for explaining this. Can you send me the information we discussed in writing or direct me to where I can find it on your website? Also, could you provide a reference number for this call in case I have further questions?”

Pro Tips:

• Have Your Policy Information Handy: Before calling, prepare your insurance ID, group number, and policy details.
• Take Notes: Write down the representative’s name, the date/time of the call, and the details of your discussion.
• Request Documentation: Ask for written confirmation of coverage or denial for future reference.