How to Obtain Diabetic Shoes for a Patient as an APRN
As an APRN, you can prescribe therapeutic diabetic footwear for eligible patients by completing a comprehensive foot examination, documenting the medical necessity based on risk stratification, and providing a written prescription that meets Medicare/insurance requirements for patients with diabetes who have evidence of peripheral neuropathy with loss of protective sensation (LOPS) and foot deformities or history of ulceration.
Step 1: Perform Risk Stratification Through Comprehensive Foot Examination
Before prescribing diabetic shoes, you must document the patient's risk category through a structured examination 1, 2:
Required Assessment Components:
Neuropathy Testing - Use the 10-g Semmes-Weinstein monofilament test as the primary assessment for LOPS 2. Add vibration testing with a 128-Hz tuning fork for additional confirmation 1.
Vascular Assessment - Palpate pedal pulses and assess for claudication history 1. Consider ankle-brachial index (ABI) if peripheral arterial disease is suspected 1, 2.
Structural Examination - Document any foot deformities including hammertoes, claw toes, bunions, prominent metatarsal heads, Charcot foot, or limited joint mobility 1.
Skin Inspection - Look for callus formation, pre-ulcerative signs (erythema, hemorrhage under callus), color changes, temperature differences, and edema 1.
History Documentation - Record any previous ulceration, amputation, end-stage renal disease, or poor glycemic control 1, 2.
Step 2: Determine Medical Necessity Based on Risk Category
Use the IWGDF Risk Classification System to justify the prescription 1:
Category 0 (No neuropathy): Standard footwear education only - therapeutic shoes not indicated 1
Category 1 (Peripheral neuropathy alone): Consider therapeutic shoes if foot deformity or pre-ulcerative signs present 1
Category 2 (Neuropathy + PAD and/or foot deformity): Prescribe therapeutic shoes with custom-made insoles 1
Category 3 (Neuropathy + history of ulcer/amputation): Prescribe therapeutic footwear with demonstrated 30% plantar pressure relief compared to standard therapeutic footwear 1
Step 3: Write the Prescription
Your written prescription must include specific documentation 1, 2:
Required Elements:
Diagnosis: Diabetes mellitus with peripheral neuropathy and LOPS (documented by monofilament testing) 2
Additional qualifying conditions: Foot deformity, history of foot ulcer, history of amputation, pre-ulcerative callus, poor circulation, or Charcot deformity 1
Prescription specifics: "Custom-molded therapeutic shoes with custom-molded insoles" or "Extra-depth therapeutic shoes with custom-molded insoles" 1
Frequency: Typically one pair per calendar year with up to 3 pairs of insoles 3
Step 4: Refer to Appropriate Footwear Specialist
Direct the patient to a certified pedorthist or therapeutic footwear specialist who can fabricate or fit the prescribed footwear 1, 4. The specialist must:
- Understand plantar pressure reduction principles 1
- Ensure proper fit that accommodates deformities without creating new pressure points 1
- Provide footwear that achieves documented pressure relief (30% reduction for Category 3 patients) 1
Step 5: Patient Education and Follow-Up
Critical Instructions to Provide:
Never walk barefoot, in socks only, or in thin-soled slippers - whether at home or outside 1
Break in new therapeutic shoes gradually to prevent blister formation 1
Wear the prescribed footwear consistently - adherence is essential for ulcer prevention 1
Inspect shoes daily before wearing, checking inside for foreign objects or rough areas 1
Follow-Up Schedule Based on Risk:
Common Pitfalls to Avoid
Do not prescribe therapeutic shoes for patients without documented LOPS - this is the primary qualifying criterion and insurance will deny coverage 2. Simply having diabetes is insufficient.
Do not rely solely on patient report of numbness - you must document objective testing with monofilament 2. Subjective symptoms alone do not meet prescription requirements.
Avoid prescribing "conventional" or "standard" therapeutic shoes for active ulcer healing - these are contraindicated for plantar ulcers and require non-removable offloading devices instead 1.
Do not assume all diabetic patients need custom-molded shoes - patients with Category 0 or 1 risk without deformities may do well with properly fitted commercial athletic or walking shoes that provide cushioning 1.
Ensure the prescription specifies "custom-molded insoles" not just "insoles" - generic inserts do not meet therapeutic requirements for high-risk patients 1.
Insurance Documentation Requirements
For Medicare and most insurance coverage, your medical record must contain 2, 3:
- Documentation of diabetes mellitus diagnosis
- Evidence of peripheral neuropathy with LOPS (monofilament test results)
- At least one additional qualifying condition (deformity, ulcer history, amputation, callus, PAD, or Charcot)
- Statement that patient is being treated under a comprehensive diabetes care plan
- Your signature and credentials as the prescribing provider
APRNs have full prescriptive authority for therapeutic diabetic footwear in accordance with their state scope of practice and can serve as the certifying physician equivalent for Medicare DME coverage 3, 4.