Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
| Contract | Contractor | Type | States |
|---|---|---|---|
| 19003 | Noridian Healthcare Solutions, LLC | DME MAC | AK AS AZ CA CNMI GU HI IA ID KS MO MT ND NE NV OR SD UT WA WY |
| 18003 | CGS Administrators, LLC | DME MAC | AL AR CO FL GA LA MS NC NM OK PR SC TN TX VA VI WV |
| 17013 | CGS Administrators, LLC | DME MAC | IL IN KY MI MN OH WI |
| 16013 | Noridian Healthcare Solutions, LLC | DME MAC | CT DC DE MA MD ME NH NJ NY PA RI VT |
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Article A52501 (Therapeutic Shoes for Persons with Diabetes - Policy Article) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A52501: Therapeutic Shoes for Persons with Diabetes - Policy Article (Article, effective 2024-12-05)
- Covered ICD-10-CM codes
- 428
- 1 group
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 0
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| E08.00 | — |
| E08.01 | — |
| E08.10 | — |
| E08.11 | — |
| E08.21 | — |
| E08.22 | — |
| E08.29 | — |
| E08.311 | — |
| E08.319 | — |
| E08.3211 | — |
| E08.3212 | — |
| E08.3213 | — |
| E08.3219 | — |
| E08.3291 | — |
| E08.3292 | — |
| E08.3293 | — |
| E08.3299 | — |
| E08.3311 | — |
| E08.3312 | — |
| E08.3313 | — |
| E08.3319 | — |
| E08.3391 | — |
| E08.3392 | — |
| E08.3393 | — |
Procedure codes named in the LCD
A5500 (For Diabetics Only, Fitting (Including Follow-Up), Custom Preparation And Supply Of Off-The-Shelf Depth-Inlay Shoe Manufactured To Accommodate Multi-Density Insert(S), Per Shoe), A5501 (For Diabetics Only, Fitting (Including Follow-Up), Custom Preparation And Supply Of Shoe Molded From Cast(S) Of Patient'S Foot (Custom Molded Shoe), Per Shoe), A5503 (For Diabetics Only, Modification (Including Fitting) Of Off-The-Shelf Depth-Inlay Shoe Or Custom-Molded Shoe With Roller Or Rigid Rocker Bottom, Per Shoe), A5504 (For Diabetics Only, Modification (Including Fitting) Of Off-The-Shelf Depth-Inlay Shoe Or Custom-Molded Shoe With Wedge(S), Per Shoe), A5505 (For Diabetics Only, Modification (Including Fitting) Of Off-The-Shelf Depth-Inlay Shoe Or Custom-Molded Shoe With Metatarsal Bar, Per Shoe), A5506 (For Diabetics Only, Modification (Including Fitting) Of Off-The-Shelf Depth-Inlay Shoe Or Custom-Molded Shoe With Off-Set Heel(S), Per Shoe), A5507 (For Diabetics Only, Not Otherwise Specified Modification (Including Fitting) Of Off-The-Shelf Depth-Inlay Shoe Or Custom-Molded Shoe, Per Shoe), A5508 (For Diabetics Only, Deluxe Feature Of Off-The-Shelf Depth-Inlay Shoe Or Custom-Molded Shoe, Per Shoe), A5510 (For Diabetics Only, Direct Formed, Compression Molded To Patient'S Foot Without External Heat Source, Multiple-Density Insert(S) Prefabricated, Per Shoe), A5512 (For Diabetics Only, Multiple Density Insert, Direct Formed, Molded To Foot After External Heat Source Of 230 Degrees Fahrenheit Or Higher, Total Contact With Patient'S Foot, Including Arch, Base Layer Minimum Of 1/4 Inch Material Of Shore A 35 Durometer Or 3/16 Inch Material Of Shore A 40 Durometer (Or Higher), Prefabricated, Each), A5513 (For Diabetics Only, Multiple Density Insert, Custom Molded From Model Of Patient'S Foot, Total Contact With Patient'S Foot, Including Arch, Base Layer Minimum Of 3/16 Inch Material Of Shore A 35 Durometer (Or Higher), Includes Arch Filler And Other Shaping Material, Custom Fabricated, Each), A5514 (For Diabetics Only, Multiple Density Insert, Made By Direct Carving With Cam Technology From A Rectified Cad Model Created From A Digitized Scan Of The Patient, Total Contact With Patient'S Foot, Including Arch, Base Layer Minimum Of 3/16 Inch Material Of Shore A 35 Durometer (Or Higher), Includes Arch Filler And Other Shaping Material, Custom Fabricated, Each).
Coverage indications, limitations and medical necessity
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.
The purpose of a Local Coverage Determination (LCD) is to provide information regarding “reasonable and necessary” criteria based on Social Security Act § 1862(a)(1)(A) provisions.
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement:
• The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
• The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.
• Refer to the Supplier Manual for additional information on documentation requirements.
• Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD.
For the items addressed in this LCD, the “reasonable and necessary” criteria, based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.
The statutory coverage criteria for therapeutic shoes including the requirement for an order are specified in the related Policy Article.
Separate inserts may be covered and dispensed independently of diabetic shoes if the supplier of the shoes verifies in writing that the beneficiary has appropriate footwear into which the insert can be placed. This footwear must meet the definitions found in this policy for depth shoes or custom-molded shoes.
A custom molded shoe (A5501) is covered when the beneficiary has a foot deformity that cannot be accommodated by a depth shoe. The nature and severity of the deformity must be well documented in the supplier's records and available upon request. If a custom molded shoe is provided but the medical record does not document why that item is medically necessary, it will be denied as not reasonable and necessary.
GENERAL
For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed Standard Written Order (SWO) before the DMEPOS item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without first receiving a WOPD, the claim shall be denied as not reasonable and necessary. Refer to the LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.
For DMEPOS base items that require a WOPD, and also require separately billed associated options, accessories, and/or supplies, the supplier must have received a WOPD which lists the base item and which may list all the associated options, accessories, and/or supplies that are separately billed prior to the delivery of the items. In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be denied as not reasonable and necessary.
An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be denied as not reasonable and necessary/incorrectly coded.
Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. Proof of delivery documentation must be made available to the Medicare contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary.
Summary of evidence (opening)
N/A
the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2015-10-01
- Current revision effective
- 2020-01-01
- Last reviewed by the contractor
- 2019-01-08
- MCD version
- 26
- Derived from
- L27040
Other related documents: A55426 (Article).
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Noridian Healthcare Solutions, LLC hub and CGS Administrators, LLC hub list every other active policy from the same contractor.
Frequently asked questions
What does LCD L33369 cover?
The statutory coverage criteria for therapeutic shoes including the requirement for an order are specified in the related Policy Article. The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L33369 apply to?
Noridian Healthcare Solutions, LLC and CGS Administrators, LLC apply it to Medicare claims in AK, AL, AR, AS, AZ, CA, CNMI, CO, CT, DC, DE, FL, GA, GU, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, PR, RI, SC, SD, TN, TX, UT, VA, VI, VT, WA, WI, WV, WY. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L33369?
The companion article article A52501 lists 428 ICD-10-CM codes in 1 group that support medical necessity; the first 24 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L33369?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.