Participant turns in a claim for New Balance Shoes

[Guest flexperplexed]

We have a Flex participant that is turning in a claim for New Balance Shoes. This person's doctor wrote a letter telling us the diagnosis and recommended "shoes with a good arch support." We have had claims submitted for orthopedic inserts and orthopedic shoes purchased at an orthopedic store but we have never had anyone submit shoes purchased from a regular shoe store with a note from the participant that these are supposed to have the best support. The doctor's letter does not specify this brand.

Would you reimburse this expense?

[WDIK]

I have no experience to base an opinion, but I did have some thoughts (some in support of, some opposed to, some indifferent to reimbursement):

1) Would the person purchase no shoes without a Dr.'s recommendation and diagnosis?

2) What would the person normally spend on a pair of shoes?

3) What are the comparable costs of shoes from an "orthopedic" store?

4) Would the reimbursement amount depend on the cost associated with the "good arch support?"

5) How could the additional cost be determined?

6) Does a doctor's recommendation translate to a medical necessity?

[Guest Blueglass]

The shoe does not appear to be for a life threading illness or to "save" a limb or to treat long term medical condition. It is obvious that this shoe was not made by a special company that works with people with a type of condition. Would you pay for foot support from Eckerds??? I would deny the claim based on lack of medical necessity. The patient has the right to appeal the claim. You can request "real" documentation stating that the shoes the participant chose are designed specifically to treat his/her condition. Documentation would need to come from the shoe manufacture (not the store worker or doctor in this case). You have everything you need from the doctor, they have some type of condition, but the product they chose does not fall under the plan.

[Guest Blueglass]

Also, there is a list of items considered under a flex plan on the web, you may want to research this further....

[Guest JTrini8302]

I don't think this can be considered an "over the counter" medication nor are New Balance Shoes "durable medical supplies" or "orthotics".

The shoes are downright comfy, I agree, but I would say no.

Before the OTC thing came into play, doctors' notes for benadryl, robitussin, etc were not reimbursable. I would think the Sneaker Predicament would fall under this situation. If the doc didn't give the person a note, I would like to think common sense would have kicked in and they would have purchased appropriate footwear anyway.

[E as in ERISA]

What is the diagnosis? Plantar fasciitis? I think that the shoes are a little more than "comfy." The condition can last a year. Wearing regular shoes without adequate arch support can exacerbate the condition -- causing tears in the ligament -- which can cause excrutiating pain -- like a knife going through the person's foot -- every time the person steps down. The stress from this condition (not being able to walk) can cause potentially cause additional symptoms (headaches, etc.) When the case is extreme, surgery may be necessary. The condition is most common among athletes. Wearing good tennis shoes can significantly improve the condition and eliminate the pain. So "good tennis shoes" is a very common "prescription."

[E as in ERISA]

http://www.newbalancecatalog.com/FeetHurt/...arFasciitis.htm

[Guest JTrini8302]

I understand shoes with good support - I myself wear sneakers and shoes at my docs request with specific support for foot/ankle/knee problems due to past athletic injuries.

However, I would still have advised my staff against reimbursement when I was in FSA admin. I see no difference in a doc writing a "prescription" for sneakers to make walking/standing more comfortable due to an injury and writing a "prescription" for OTC meds for a cold or flu previous to the OTC changes.

I tend to think that making the allowance for reimbursement may set a precedent and might come back to bite you in the end. I'd rather deny up front. Or, pend for more info if you feel you should at least pursue.

'Tis a confusing one and I don't envy you having to make the decision.

[E as in ERISA]

Yes. I'm not saying what the answer is for the FSA. But more than "comfort" is involved and New Balance are designed with feet problems like this in mind....

[Guest JTrini8302]

My personal sneaker of choice is Asics, but I know from the several runners in my family the New Balance line is also designed very well and is the shoe of choice for a couple of them specifically because of their support and comfort over 26 miles of pounding pavement.

I'm still iffy on the necessity side of things though, so I call a truce and agree to disagree.