If a patient is not a diabetic and has a partial foot amputation does Medicare cover a partial foot filler (L5000)
The short answer is that whether the patient is diabetic or not, the L5000 would be covered under the lower limb prosthetic LCD. That is, an L5000 is defined as Partial foot, shoe insert with longitudinal arch, toe filler and not the diabetic shoe program.
The medical necessity for a partial foot, toe filler device is dependent on your documentation of how the patient’s gait has been altered by the amputation. Furthermore, your chart would need to support that the device will stabilize the patient sufficiently to restore a more normal gait.
While the initial intent of the L5000 was to be restricted to at a minimum of a trans-metatarsal amputation, recent decisions have allowed a bit more liberal interpretation. Thus, the loss of a major external (first and/or fifth or multiple central rays) may still qualify the patient for an L5000 prosthesis.
If the patient only has a single partial toe amputation which does not affect balance and stability and create shoe fitting issues, a toe plug for that patient will not likely qualify for L5000.
Because the L5000 prosthesis coverage is listed within the lower limb prosthesis LCD, the qualifications spelled out in the therapeutic shoe program for patients with diabetes DO NOT apply.
