This is real.

A Nurse Practitioner can:

• Diagnose diabetes

• Prescribe insulin

• Manage CKD

• Treat foot ulcers

• Adjust complex medication regimens

But under Medicare, an NP cannot independently order therapeutic diabetic shoes.

Only a physician can sign the certification.

So in many NP-owned practices, here’s what happens:

The NP evaluates the patient.
Determines shoes are medically necessary.
Completes the documentation.

Then pays a collaborating physician to sign the form.

Not to examine the patient. Not to change the plan. Just to sign.

It would be funny if it weren’t routine.

Why Is This Even a Rule?

Because of how the law was written.

The Medicare therapeutic shoe benefit was created in the 1990s. At the time, Congress explicitly limited certification authority to physicians. NPs weren’t written into the statute.

And when something is written directly into federal law, CMS can’t just “update a policy.” It takes legislative change to fix it.

So yes — technically, it would take Congress to allow NPs to independently order diabetic shoes for Medicare patients.

That’s why this still exists.

Not because of training. Not because of safety. Because of old statutory language.

The Real Cost

For independent NP practices, this isn’t philosophical.

It’s financial.

• Paying collaborators for signatures

• Administrative time

• Extra coordination

• Delays for patients

And for patients — especially in rural areas where the NP is their primary provider — it adds friction to something that’s supposed to prevent serious complications.

Therapeutic footwear reduces ulcers and amputations. The clinical judgment already happened. The second signature doesn’t improve care.

It satisfies a 1990s drafting decision.

Healthcare has evolved. NP scope has evolved. Primary care delivery has evolved.

The statute hasn’t.

When someone can manage insulin but can’t sign for shoes, the mismatch is hard to ignore.

Sometimes policy doesn’t need outrage.

It just needs updating.