Does Insurance Cover Custom Orthotics? What You Need to Know

One of the most common questions we hear is whether insurance will cover custom orthotics. The short answer: it depends on your plan, your diagnosis, and how the claim is documented. The longer answer involves understanding how insurance companies evaluate orthotic claims and what you can do to maximize your coverage.

The General Landscape

Custom orthotics are classified as durable medical equipment (DME) by most insurers. Like other DME — braces, splints, surgical shoes — coverage varies significantly by plan. Some plans cover custom orthotics generously; others exclude them entirely; most fall somewhere in between with conditions and limitations.

The trend in recent years has been toward more restrictive orthotic coverage. Many plans have moved from covering custom orthotics to covering only "prefabricated" (off-the-shelf) orthotics, or limiting coverage to specific diagnoses. Understanding your specific plan is essential before assuming coverage.

What Insurance Typically Requires

When custom orthotics are a covered benefit, insurance companies generally require several things for approval.

Medical necessity. Orthotics must be prescribed for a documented medical condition — not for comfort or general wellness. Diagnoses that commonly support medical necessity include plantar fasciitis, posterior tibial tendon dysfunction, adult-acquired flatfoot, metatarsalgia, diabetic neuropathy with foot deformity, and significant biomechanical abnormalities contributing to pain.

Failed conservative treatment. Some plans require documentation that simpler measures (stretching, over-the-counter insoles, physical therapy, shoe changes) were tried first and didn't adequately resolve the problem. This "step therapy" requirement means your podiatrist may need to document the progression of treatment.

Clinical examination and prescription. The orthotics must be prescribed by a qualified provider (podiatrist, orthopedist) based on a clinical examination that includes a biomechanical assessment. A prescription for orthotics without an accompanying examination generally won't be approved.

Custom fabrication from a mold or scan. The distinction between custom orthotics (fabricated from an impression of your individual foot) and prefabricated orthotics (mass-produced and modified to fit) matters for billing and coverage. True custom orthotics are fabricated from a plaster cast, foam impression, or 3D scan of your foot.

Plan Types and What to Expect

PPO plans are generally the most favorable for orthotic coverage. Many PPO plans cover custom orthotics with a copay or coinsurance after the deductible is met. Some limit coverage to one pair every 2–3 years.

HMO plans may cover orthotics but typically require a referral from your primary care physician and may limit you to specific providers or DME suppliers. Some HMO plans only cover prefabricated orthotics.

Medicare Part B covers custom therapeutic shoes and inserts for patients with diabetes who have a qualifying foot condition (neuropathy, prior ulceration, foot deformity, poor circulation, calluses with risk of breakdown). The qualifying conditions must be certified by the treating physician. Coverage typically includes one pair of custom molded shoes or one pair of depth shoes with 3 pairs of inserts per calendar year.

Workers' compensation and auto injury plans generally cover custom orthotics when they're related to the work or auto injury and prescribed as part of the treatment plan.

HSA and FSA accounts can be used for custom orthotics regardless of whether your insurance plan covers them, since orthotics are a qualifying medical expense.

What If Insurance Doesn't Cover Orthotics?

If your plan doesn't cover custom orthotics — or if the out-of-pocket cost after insurance isn't manageable — there are alternatives to consider.

High-quality prefabricated orthotics that your podiatrist selects and modifies for your foot can be a cost-effective option for milder biomechanical issues. They're not identical to custom devices but can be significantly better than generic drugstore insoles.

Self-pay pricing for custom orthotics is sometimes less than you'd expect — and when you consider that a quality custom orthotic lasts 2–5 years, the per-year cost is comparable to buying premium shoe insoles annually. We offer transparent self-pay pricing and are happy to discuss costs upfront.

Using your HSA or FSA is essentially paying with pre-tax dollars, which represents a 20–35% discount depending on your tax bracket.

How We Handle the Insurance Process

At Fallbrook Podiatry, we verify your orthotic benefit before you commit to treatment. Our team checks your specific plan, confirms whether custom orthotics are covered, identifies any preauthorization requirements, and gives you an estimate of your out-of-pocket cost. We handle the documentation, coding, and submission — our goal is to make the process as straightforward as possible so you can focus on getting the treatment you need.

The most important thing is not to let insurance uncertainty prevent you from getting orthotics if you need them. An evaluation can determine whether custom orthotics are the right treatment for your condition, and then we can work together to figure out the most cost-effective path forward.