Orthotic devices are a covered benefit and must be medically necessary to diagnose or treat a covered condition, approved by the U.S. Food and Drug Administration (FDA) and provided by a TRICARE-authorized provider. Coverage includes, but is not limited to:
- spinal (thoracic, cervical, lumbar, sacral),
- lower limb (hip, knee, angle-foot, knee-foot-ankle, and hip-knee-ankle-foot, plus the orthopedic shoe(s) that are an integral part of the brace),
- upper limb (shoulder elbow, wrist-hand-finger), and
- braces for leg arm, neck back and shoulder.
Note: Benefits for foot orthotics and cranial orthotics are very limited.
To expedite the review process, providers may attach a Letter of Attestation in lieu of clinical documentation to the authorization request.
Orthotics for Active Duty Service Members
Custom-fitted orthotics (for example, shoe inserts for plantar fasciitis, flat feet or similar diagnoses) are a covered benefit for active duty service members and must be ordered by the appropriate provider and obtained from a TRICARE-authorized vendor that specializes in this service. Prefabricated or other types of orthoses available in commercial retail entities are excluded.
Therapeutic Shoes for Diabetics
For individuals with diabetes, extra-depth shoes with inserts or custom molded shoes with inserts (HCPCS A5500–A5514) are covered. Documentation must be signed by the physician managing the beneficiary's diabetic condition and submitted with the claim. The claim must include a diabetes diagnosis and documentation of one of the following:
- previous amputation of the foot or part of the foot,
- history of previous foot ulceration,
- pre-ulcerative callus formation, or peripheral neuropathy with a history of callus formation, foot deformity, or poor circulation, or
- the patient is being treated under a comprehensive plan of care for diabetes and needs therapeutic shoes.
Coverage of footwear and inserts for diabetics is limited to one of the following within one (every 365 days):
- One pair of custom molded shoes (including inserts provided with such shoes) and two pairs of multidensity inserts
- One pair of extra-depth shoes (not including inserts provided with such shoes) and three pairs of multidensity inserts
- Modification of custom-molded or extra-depth shoes may be substituted for one pair of inserts, other than the initial pair of inserts
- Additional items, such as socks (L2840 and L2850)
Orthopedic braces with shoes are covered if the shoe is an integral part of the brace (neither the shoe nor the brace is usable separately).
A dynamic orthotic cranioplastly (DOC) band post-op device is covered for infants from 3–18 months of age whose synostosis has been surgically corrected, but who still have moderate to severe cranial deformities.
Orthotics may be replaced at any time if there is a change in the beneficiary’s condition to include patient growth making the orthotic not useful. Otherwise, replacements may be allowed once a year* (every 365 days), if worn or damaged, but still serviceable.
*For beneficiaries under the age of 18, outgrown orthoses may be replaced earlier than once a year with appropriate documentation from the provider.
Orthotics Not Covered
The following devices are not covered:
- orthopedic shoes (except for orthopedic shoes that are an integral part of a brace in which neither the brace nor the shoe could be used separately)
- arch supports
- shoe inserts (except as indicated above for diabetics and active duty service members)
- other supportive devices of the feet, such as wedges, specialized fillers, heel straps, pads, and shanks
- cranial orthosis and cranial molding helmets for nonsynsostotic positional plagiocephaly (deformational plagiocephaly, plagiocephaly without synostosis) or for the treatment of craniosynostosis before surgery