Does A5501 require prior authorization?

Yes, A5501 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for A5501?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`A5501`, For diabetics only, fitting (including follow-up), custom preparation and

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Supplier must have received a signed Standard Written Order (SWO)/Written Order Prior to Delivery (WOPD) before delivering DMEPOS base items; the WOPD must list the base item and may list associated options/accessories/supplies.

Suppliers must follow additional documentation/payment rules in the LCD-related Standard Documentation Requirements Article, LCD-related Policy Article, Supplier Manual, and DME MAC web bulletins.

Key Coverage Criteria

Therapeutic shoes and related inserts are covered when the item is an eligible Medicare benefit category and is reasonable and necessary for diagnosis or treatment of illness/injury or to improve the functioning of a malformed body member.
Therapeutic shoes are provided for persons with diabetes when the above Medicare coverage criteria are met.
A custom-molded shoe (HCPCS A5501) is covered when the beneficiary has a foot deformity that cannot be accommodated by a depth shoe and the nature and severity of the deformity are documented.
Separate inserts may be covered and dispensed independently if the supplier documents in writing that the beneficiary has appropriate footwear (depth shoes or custom-molded shoes) into which the insert can be placed.
History of pre-ulcerative calluses of either foot;or
History of previous foot ulceration of either foot;or

3 Active Policies

ANTHEM-CG-DME-19, Therapeutic Shoes, Inserts, or Modifications for Individuals with Diabetes

EVICORE-HPLAN-CIGNA_MEDICARE-268F28B96146, Cigna Medicare Advantage Durable Medical Equipment Code List - Effective 01/01/2025

L33369, Therapeutic Shoes for Persons with Diabetes

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A5501, For diabetics only, fitting (including follow-up), custom preparation and