What documentation is required for a patient with diabetes (Diabetes Mellitus) to receive diabetic shoes?

Documentation Required for Diabetic Shoe Coverage

To receive diabetic shoes, patients must have documented evidence of diabetes mellitus plus at least one of the following qualifying conditions: peripheral neuropathy with loss of protective sensation (LOPS), foot deformity, history of foot ulceration, or history of amputation. 1

Required Clinical Documentation

1. Diabetes Diagnosis Confirmation

• Document the diagnosis of diabetes mellitus (Type 1 or Type 2) in the medical record 2, 1

2. Risk Stratification Assessment

The patient must be classified into a qualifying risk category based on the International Working Group on the Diabetic Foot (IWGDF) Risk Classification System 1:

• Category 1 (Qualifies): Peripheral neuropathy with LOPS alone 2, 1
• Category 2 (Qualifies): Peripheral neuropathy with peripheral arterial disease (PAD) and/or foot deformity 2, 1
• Category 3 (Qualifies): Peripheral neuropathy with history of foot ulcer or amputation 2, 1

Note: Category 0 patients (no peripheral neuropathy) do not qualify for therapeutic diabetic shoes and can use off-the-shelf footwear 2

3. Neurological Assessment Documentation

Document LOPS using at least two of the following tests 2:

• 10-g Semmes-Weinstein monofilament test (primary test - absent sensation indicates LOPS) 2, 1
• 128-Hz tuning fork for vibration perception 2, 1
• Pinprick testing on dorsum of foot 2
• Achilles tendon reflexes 2

At least two abnormal tests confirm LOPS 2

4. Structural Foot Examination Documentation

Document any foot deformities present 1:

• Hammertoes or claw toes 2, 1
• Bunions or prominent metatarsal heads 2, 1
• Charcot foot deformity 2, 1
• Limited joint mobility 1
• Evidence of abnormal loading (callus formation, hyperemia) 2, 1

5. Vascular Assessment Documentation

• Palpation of pedal pulses 2, 1
• Ankle-brachial index (ABI) if PAD is suspected 2
• History of claudication or decreased walking speed 2

6. Skin and Ulcer History Documentation

• Document any current or previous foot ulcers 1
• Document history of amputation 1
• Document pre-ulcerative signs (calluses, blisters, temperature changes) 2, 1

7. Footwear Prescription Justification

For Category 2 patients: Prescribe therapeutic shoes with custom-made insoles 1

For Category 3 patients: Prescribe therapeutic footwear with demonstrated 30% plantar pressure relief compared to standard therapeutic footwear 1

Common Pitfalls to Avoid

• Insufficient neuropathy testing: Using only one test for LOPS is inadequate - document at least two tests with at least one abnormal result 2
• Missing risk stratification: Failing to classify patients using the IWGDF system can result in coverage denial 1
• Inadequate deformity documentation: Simply noting "foot deformity" without specifying the type and location may not satisfy coverage requirements 1
• Omitting ulcer history: Previous ulceration, even if healed, is a critical qualifying criterion that must be documented 1

Follow-Up Documentation Requirements

Document the prescribed follow-up schedule based on risk category 1:

• Category 1: Every 6 months 1
• Category 2: Every 3-6 months 1
• Category 3: Every 1-3 months 1