Are Custom Orthotics Covered by Insurance?

Custom foot orthotics — prescription devices fabricated from a three-dimensional mold of the patient’s foot to provide individualized biomechanical control — are among the most therapeutically valuable tools in podiatric care. They are also among the most misunderstood in terms of insurance coverage. The answer to whether orthotics are covered is ‘it depends’ — on your specific insurance plan, on the diagnosis documented in your medical record, and on whether the device meets the plan’s definition of a covered durable medical equipment (DME) benefit. Understanding how this coverage works helps patients maximize their benefits and avoid unexpected out-of-pocket costs.

Medicare Coverage for Custom Orthotics

Medicare Part B covers custom-molded shoe inserts (orthotics) as a benefit under the therapeutic shoe program for qualifying diabetic patients. The therapeutic shoe benefit — established under the Medicare Improvements for Patients and Providers Act — provides for one pair of extra-depth shoes and three pairs of custom-molded inserts per calendar year for Medicare beneficiaries with diabetes who meet the clinical eligibility criteria.

Medicare Eligibility Requirements for Diabetic Footwear

To qualify for the Medicare therapeutic shoe benefit, a patient must: (1) have diabetes mellitus (Type 1 or Type 2); (2) have at least one of the following: peripheral neuropathy with callus formation, history of pre-ulcerative callus, history of foot ulceration, foot deformity, poor circulation, or prior amputation; (3) have a certifying physician (treating physician, endocrinologist, or podiatrist who is not the shoe prescriber) document medical necessity; and (4) not be in a skilled nursing facility or other nursing care setting where footwear is included in the care program.

Medicare pays 80% of the approved amount for diabetic shoes and inserts; the beneficiary is responsible for the 20% coinsurance. With secondary insurance (Medicare supplement/Medigap) this coinsurance may be covered at 100%, resulting in no out-of-pocket cost to the patient.

Commercial Insurance Coverage: Blue Cross, Aetna, Cigna, United Healthcare

Coverage for custom orthotics under commercial insurance plans varies significantly by plan. Many plans cover custom-molded orthotics as durable medical equipment (DME) with a prescription for specific diagnoses. Commonly covered diagnoses include: plantar fasciitis (L60.0), hallux valgus (M20.11), posterior tibial tendon dysfunction (M76.82), pes planus (M21.40), diabetes-related foot conditions (various), metatarsalgia (M77.41), and others.

Key variables that affect coverage include: whether the plan has an orthotic benefit at all (some plans exclude orthotics entirely), whether the orthotics are obtained from a participating in-network provider, whether prior authorization is required (increasingly common), the specific diagnoses documented in the patient’s medical record, and the plan’s deductible, copay, and coinsurance terms. Flexible spending accounts (FSAs) and health savings accounts (HSAs) can be used for custom orthotics without restriction.

What Documentation Is Required

Insurance coverage for custom orthotics requires thorough clinical documentation establishing medical necessity. This documentation typically includes: a physician or podiatrist’s prescription specifying the diagnosis, the clinical examination findings (gait analysis, arch height assessment, biomechanical findings), documentation of prior conservative treatment attempts (stretching, OTC insoles) and their failure, the clinical rationale for custom rather than off-the-shelf orthotics, and the specific functional goals the orthotics are intended to address. Inadequate documentation is the most common reason for orthotics coverage denial — a denial that can often be successfully appealed with proper documentation provided upon request.

Prior Authorization: What to Expect

Many commercial plans now require prior authorization (PA) before custom orthotics will be covered. The PA process involves submission of clinical documentation by the provider’s office to the insurance plan’s medical review team, which evaluates whether the request meets coverage criteria. PA decisions are typically returned within 5–14 business days. If the PA is approved, orthotics can be fabricated and the insurance claim submitted. If denied, patients have the right to appeal — and appeals are frequently successful when adequate supporting documentation is provided. Our office handles the prior authorization process on behalf of patients and has experience navigating both approval and appeal processes.

Over-the-Counter vs. Custom Orthotics: Why the Difference Matters for Coverage

Insurance plans distinguish between prefabricated (OTC) and custom-molded orthotics for coverage purposes. Custom-molded orthotics — fabricated from an individual three-dimensional mold of the patient’s foot — are covered as DME when medical necessity criteria are met. Prefabricated OTC insoles — whether purchased at a pharmacy, shoe store, or online — are generally not covered by insurance as they are considered personal comfort items rather than medical devices. This distinction matters both for coverage and for clinical outcomes: custom-molded orthotics provide individualized support based on the specific anatomy of the patient’s foot, while OTC insoles provide generic support that may or may not address the patient’s specific biomechanical needs.

The Insurance Process at Balance Foot & Ankle

Our team assists patients with every aspect of the orthotics insurance process: verifying your specific plan’s orthotics benefit before fabrication, obtaining prior authorization when required, submitting claims with appropriate diagnosis codes and documentation, and assisting with appeals if an initial claim is denied. We are in-network with most major Michigan insurance plans, and our billing team is experienced with the full spectrum of insurance requirements for custom orthotics coverage. Contact our office to discuss your specific insurance plan’s benefits and whether your foot condition qualifies for covered orthotics fabrication.

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Balance Foot & Ankle serves Southeast Michigan — same-week appointments, most insurance accepted.

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Dr. Tom Biernacki, DPM

Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.