Medicare covers some orthotics, but not all — and the rules depend on whether you have Original Medicare or a Medicare Advantage plan

Original Medicare (Parts A and B) covers orthotics only when they are prescribed by a doctor for a specific medical condition and meet Medicare's definition of a prosthetic device. This means custom-made shoe inserts for severe flat feet, ankle braces after surgery, or spinal supports for documented spinal problems may be covered. However, over-the-counter orthotics — the kind you buy at a drugstore or online — are not covered under any Medicare plan.

The coverage also depends on whether your orthotics are considered "shoes" or "shoe inserts." Medicare has a narrow category called "orthopedic shoes" that it covers in very specific cases, usually after amputation or severe foot deformity. Regular orthotics inserted into your own shoes fall into a different category and face stricter limits.

If you have a Medicare Advantage plan (Part C), your coverage may be different. Some plans offer additional benefits for orthotics that Original Medicare does not, but you will need to check your plan's summary of benefits or call the plan directly to know what yours covers.

Key Takeaways

  • Original Medicare covers orthotics only when prescribed by a doctor for a medical condition and deemed medically necessary, not for general comfort or prevention.
  • You must use a Medicare-approved supplier and obtain prior authorization from Medicare before you purchase the orthotics, or you may have to pay the full cost yourself.
  • Medicare typically covers 80 percent of the approved amount after you meet your Part B deductible; you pay the remaining 20 percent.
  • Medicare Advantage plans may cover orthotics differently, so you should contact your specific plan to learn what is included in your coverage.
  • Over-the-counter orthotics purchased without a prescription are never covered by any Medicare plan.

When Original Medicare will cover orthotics

Original Medicare covers orthotics under Part B when all of these conditions are met: a doctor has prescribed them, they treat a specific medical condition (not general foot pain or prevention), and they are made by or fitted by a Medicare-approved supplier. Common reasons Medicare approves orthotics include severe arthritis affecting the foot or ankle, post-surgical support after foot or ankle surgery, diabetic neuropathy with documented foot damage, and significant structural deformities of the foot or spine.

The orthotics must also be considered "medically necessary" — meaning the condition cannot be safely managed without them. If your doctor says orthotics would help but are not essential, Medicare will likely deny the claim. The difference matters: "helpful" is not the same as "medically necessary" in Medicare's view.

Your doctor does not have to be a podiatrist or orthopedic surgeon. Any physician can prescribe orthotics, but the prescription must include specific details about your diagnosis, why the orthotics are needed, and what type of device is required. A vague prescription like "patient needs arch support" will not pass Medicare's review.

How to get Medicare approval before you buy

The most important step is to get prior authorization from Medicare before you purchase the orthotics. This means your doctor or the supplier submits paperwork to Medicare, and Medicare says yes or no before you spend money. If you buy orthotics without prior authorization and Medicare later denies them, you will owe the full cost.

Here is the typical order of steps: your doctor writes a prescription that includes your diagnosis and medical reason for the orthotics; you find a Medicare-approved supplier (your doctor's office can usually provide a list, or you can search the Medicare Supplier Directory online); the supplier submits the prescription and supporting medical records to Medicare for review; Medicare reviews the claim and sends a decision, usually within two weeks; if approved, you can proceed with the fitting and purchase.

Do not skip the prior authorization step. Many people assume their doctor's prescription is enough, then receive a bill from the supplier after Medicare denies the claim. The supplier is not responsible for the denial — you are.

What you will pay out of pocket

If Medicare approves your orthotics, you pay 20 percent of the Medicare-approved amount after you have met your Part B deductible for the year. The Medicare-approved amount is not the same as the supplier's asking price. Medicare sets a maximum it will pay for each type of orthotics, and your cost is 20 percent of that maximum, not 20 percent of what the supplier charges.

For example, if Medicare's approved amount for a pair of custom foot orthotics is $500, Medicare pays $400 (80 percent) and you pay $100 (20 percent). If the supplier charges $800, you still pay only $100 — the supplier must accept Medicare's approved amount as payment in full. However, if you have not met your Part B deductible, you pay the full approved amount until the deductible is satisfied, then Medicare's 80/20 split begins.

The exact amount varies by the type of orthotics and your location. There is no single price list you can look up in advance, but your supplier can tell you the Medicare-approved amount before you commit to the purchase.

Medicare Advantage plans and orthotics coverage

Medicare Advantage plans (Part C) are required to cover at least what Original Medicare covers, but many plans offer additional orthotics benefits. Some plans cover over-the-counter orthotics, offer a higher percentage of coverage, or waive the prior authorization requirement. Others have the same rules as Original Medicare.

The only way to know what your plan covers is to check your plan's Summary of Benefits and Coverage document (you should have received this when you enrolled) or call your plan's customer service number. The coverage can change year to year, so even if your plan covered orthotics last year, you should verify for the current year.

If your plan does cover orthotics beyond what Original Medicare covers, you still need a doctor's prescription and must use a network supplier. Using an out-of-network supplier may result in higher out-of-pocket costs or no coverage at all.

Orthotics that Medicare does not cover

Medicare does not cover orthotics for general foot pain, flat feet without a documented medical condition, heel pain (plantar fasciitis), bunions, or hammertoes unless they are severe enough to be considered a structural deformity. It also does not cover orthotics for athletic performance, comfort, or prevention of future problems.

Over-the-counter orthotics — even if prescribed by your doctor — are not covered. If your doctor recommends a specific brand or model available without a prescription, you will pay for it yourself. Some people mistakenly believe that having a doctor's prescription makes an over-the-counter product covered by Medicare; it does not.

Orthotics for conditions like diabetes-related foot pain may be covered if you have documented nerve damage (neuropathy) with visible foot changes, but not for diabetes alone. The bar for coverage is high, and your medical records must support the medical necessity claim.

What to do if Medicare denies your orthotics claim

If Medicare denies your claim, you have the right to appeal. The denial letter will explain the reason — usually that the orthotics were not deemed medically necessary, the prescription lacked required details, or the supplier was not Medicare-approved.

If the reason is a missing detail in the prescription, ask your doctor to submit additional medical records or a more detailed prescription and resubmit. If the reason is that the supplier was not Medicare-approved, you can switch to an approved supplier and resubmit. If Medicare says the condition does not meet its definition of medical necessity, you can request a peer-to-peer review, where your doctor speaks directly with a Medicare medical reviewer to discuss your case.

The appeal process has strict time limits — usually 180 days from the date of the denial letter. Do not wait. Contact your doctor's office or the supplier to start the appeal as soon as you receive the denial.

Frequently Asked Questions

Can I use my Medigap plan to cover orthotics that Original Medicare does not cover?

No. Medigap plans (supplemental insurance) cover only what Original Medicare covers. If Medicare denies orthotics, your Medigap plan will not pay for them either. However, if Medicare approves orthotics and you owe the 20 percent coinsurance, some Medigap plans will pay that 20 percent.

Do I need a referral to see a podiatrist for orthotics?

No. Original Medicare does not require a referral to see a podiatrist. However, if you have a Medicare Advantage plan, check your plan's rules — some require a referral, and some do not. A podiatrist can write the prescription for orthotics, but the prescription still must meet Medicare's medical necessity standard.

What if my doctor prescribes orthotics but I cannot afford the 20 percent I owe?

Talk to the supplier about payment plans. Many suppliers offer monthly payment options. You can also ask your doctor whether a less expensive type of orthotics might work for your condition — sometimes a simpler device is medically appropriate and costs less. If cost is a barrier, your local Area Agency on Aging may know of community resources or charitable programs that help with medical equipment costs.

Can I get orthotics covered if I am on both Medicare and Medicaid?

Yes, but the process is complex. Medicare is the primary payer, so you must go through Medicare first. If Medicare approves and you owe the 20 percent coinsurance, Medicaid may cover that amount — but only if your state's Medicaid program covers orthotics and you meet your state's income and asset limits. Contact your state Medicaid office to learn your state's rules.

Are custom orthotics more likely to be covered than prefabricated ones?

Yes. Medicare is more likely to approve custom-made orthotics because they are considered more medically necessary than off-the-shelf versions. However, custom does not may provide approval — the underlying medical condition must still meet Medicare's standard. A prefabricated orthotic can be covered if it is the appropriate treatment for your condition and prescribed by a doctor.