Point Person:

• Diabetic Shoes/Supplies: Medical Records team (Carolyn Lawrence)

CGMs and Diabetic Testing Supplies: see Diabetes Supplies

Diabetic Shoes

There is a form from Medicare called “Statement of Certifying Physician for Therapeutic Shoes” that will need to be completed as part of this process (available online or here Therapeuticshoes.cms.gov). Commercial insurances may have their own form.

Eligibility

1. Patient must have diabetes with A1c > 6.5%.
2. Patient must have foot exam in chart documenting location of any callouses, ulcers, or other lesions.
3. Detailed information is needed to complete the form, including any previous amputation, history of foot ulcer, pre-ulcerative callous, peripheral neuropathy AND callous formation, foot deformity, arterial insufficiency. Include ICD-10 codes and length of need.

Initial Order

1. Complete form and document in a note all information as above.
2. Place order for “Diabetic shoes with inserts” and print.
3. Residents should be able to sign these orders. Place in medical records bin.