Contrary to your insurance company's information, we have found that most times custom orthotic coverage usually has little to do with medical necessity; though some carriers are complying with state mandates for certain conditions. Which means your insurance company can agree that they are medically necessary, but still not cover them because they are a policy exclusion.

In most situations when the insurance premium is partially paid by the employer, the employees and their dependants are subject to the provisions written in their plan documents. Each employee has a right to a full length copy, usually 100-200 page plan documents that disclose the employer's specific coverage limitations.  

Many employers have excluded custom orthotics as a covered benefit, as a way to save their company the out of pocket expense of a custom item.

More recently due to a number of state mandates, employers are modifying the language of their benefits to include orthotics for certain medical conditions (example diabetic conditions or before or after surgery).

Currently Medicare interprets custom orthotics as a preventive service and therefore does not cover the custom item, unless it is an integral part of a brace. Medicare will cover diabetic shoes and inserts annually, but only if the patient meets strict requirements. For more information on Medicare coverage of diabetic shoes, contact us at Healthy Steps.

If you would like more information about orthotic coverage, please contact our Business team for more personal information. Remember that "medically necessary" does not always mean "covered by my insurance".