Does Medicare Cover Orthotics For Plantar Fasciitis

Medicare will cover the payment for orthotics for plantar fasciitis if it is associated with another medical condition like a diabetes-related foot condition or a severe deformity. The orthotics must, however, be a medical necessity, and a prescription must be provided as proof.

Key Takeaways

• Medicare offers conditional coverage for orthotics for plantar fasciitis. The condition has to be linked to another medical condition that qualifies for Medicare.
• In qualifying cases, over-the-counter orthotics and those gotten without a doctor's prescription will not be covered.
• To improve your chances of claim approval, only get your orthotics from Medicare-approved suppliers.
• Rejected claims can be appealed and won with the right documentation.

What is Plantar Fasciitis?

Plantar fasciitis, also known as policeman's heels, is a common and painful condition caused by plantar fascia inflammation. While orthotics alleviate the discomfort and improve the mobility of people suffering from plantar fasciitis, insurance companies like Medicare have policies regarding coverage.

This guide will tell you everything you need to know about Medicare policy for orthotics for plantar fasciitis.

Medicare Coverage Determination Process

Medicare only covers items and services necessary for diagnosing or treating an illness or injury. It has to be within the scope of a Medicare benefit category. If you are under Original Medicare, both Part A (the hospital insurance) and Part B (medical insurance, your inpatient hospital care, doctors’ services, tests, and preventive services) will be covered. You must lawfully be in the United States for Medicare to cover the services of Parts A and B.

Medicare prioritizes certain conditions, like diabetes, severe deformities, and post-surgery needs, where foot-related complications pose significant risks to overall health. However, Medicare does not cover prefabricated orthotics or shoe inserts, orthotics purchased without a prescription, orthotics for conditions that do not meet the medical requirements, and orthotics from non-Medicare-approved suppliers.

Medicare's Policy Coverage for Plantar Fasciitis

While Medicare Part B covers Durable Medical Equipment (DME), like orthotics, you must provide a note from a healthcare professional proving that the orthotics are required for important medical reasons. Let’s explore Medicare coverage for Plantar Fasciitis: 

1. Medicare covers prosthetics, braces, and therapeutic shoes for diabetic-related complications and other approved diagnoses. 

2. Medicare will not cover orthotics for plantar fasciitis unless it is associated with another medical condition like diabetes-related complications and severe foot deformity. 

3. Medicare does not cover the cost of prefabricated orthotics, as they are not considered medically needed. They are deemed over-the-counter products and not durable medical equipment. 

4. You can always confirm Medicare coverage by contacting Medicare customer support. 

Steps to Secure Medicare Coverage for Plantar Fasciitis

Certain steps must be followed to improve your chances of getting your orthotics covered by Medicare.

1. Consult with your doctor: Once your medical condition has been determined and orthotics are recommended for recovery, you must ensure that your doctor provides a detailed prescription and note that will be submitted to Medicare.

2. Use Medicare-enrolled healthcare providers and suppliers: Medicare will only cover the cost of orthotics if prescribed by Medicare-approved healthcare experts and produced by a Medicare-approved supply. You should confirm the supplier’s eligibility to avoid out-of-pocket expenses.

3. Request Pre-authorization: Some Medicare plans require prior approval for custom orthotics. You should check with your Original Medicare or Medicare Advantage plan to confirm the process.

4. Understand your costs: For Medicare, you must be aware of the deductibles, coinsurance, and any other additional fees associated with your plan. For example, Medicare will cover only 80% of the cost of getting the orthotics. You will provide the remaining 20%. 

Note: Medicare will only cover the cost of your orthotics if plantar fasciitis is related to other conditions like diabetes-related complications, severe foot complications or to prevent amputation. Plantar fasciitis alone cannot trigger Medicare coverage. 

What Do I Do If Medicare Rejects My Claim

If Medicare rejects your claim, you will be notified through any of the following: a Medicare Summary Notice (MSN), an Explanation of Benefits (EOB), direct notification from your supplier/healthcare provider, or an Advanced Beneficiary Notice (ABN).

You can take the following steps if you get notified that Medicare has denied your claim: 

1. Assess the Reason for Denial: You should thoroughly read through any Medicare emails sent to you to ascertain their reasons. 

2. Contact Medicare or Your Plan Provider: If you do not understand why your claim was denied, contact Medicare at 1-800-MEDICARE or 1-800-633-4227 for further clarification.

3. Appeal the Decision: You can appeal the decision if you believe it was an error. Instructions that will guide you on how to start the process will be provided on your MSN or EOB.

4. Consult Your Healthcare Provider: Your doctor or supplier may be in the best position to provide additional documentation that will support your claim.

Can Orthotics Help with Plantar Fasciitis?

Orthotics can be used to support people with plantar fasciitis by cushioning the affected area. The orthotics can also address the condition's root causes and improve overall foot mechanics. These help reduce pain and prevent further damage. Here are the key benefits of orthotics for plantar fasciitis.

1. Arch Support: Orthotics help distribute pressure evenly across the foot by supporting the arch, which reduces strain on the plantar fascia.

2. Heel Cushioning: Orthotics help ease the heel pain commonly associated with plantar fasciitis by absorbing shock and providing extra padding.

3. Improved alignment: Properly designed orthotics can correct biomedical issues such as flat feet contributing to plantar fasciitis.

4. Pain Relief: Once the inflammation and stress on the plantar fascia is reduced with orthotics, patients can walk and comfortably stand for longer periods.

5. Prevention of further injury: Orthotics treat existing injuries and prevent their condition from worsening by promoting other foot postures.

Which is Better for Plantar Fasciitis: Prefabricated or Custom Orthotics?

You have two options when it comes to selecting an orthotic device: prefabricated and custom. You should always choose the one that will be best for your foot condition. 

Prefabricated Orthotics: While they are generally cheaper and easier to afford and are regarded as over-the-counter orthotics. They also do not address the unique foot structures or severe cases of plantar fasciitis. Medicare does not cover prefabricated orthotics. 

Custom Orthotics: These orthotics are designed specifically for your foot structure and biomechanics. They are prescribed by podiatrists or orthopedic specialists and produced by companies like Stride Soles. These orthotics are covered by Medicare once they have been proven to be a medical necessity for diabetes-related complications and severe foot deformity. 

Conclusion

Although Medicare's coverage for orthotics for plantar fasciitis might be limited, orthotics are a vital tool that will help manage painful conditions. If you decide to use Medicare, you should understand its coverage options and explore other funding strategies to reduce out-of-pocket expenses. Whether you eventually decide on prefabricated or custom orthotics, it is important to address plantar fasciitis early to enhance your overall quality of life.