10/18/2021

Healthfirst Denials-Diabetic Shoes and Inserts

We are not getting paid on Healthfirst claims for diabetic depth shoes and custom inserts which we always used to get paid for. We are obtaining the ARQ Authorization-numbers off of their website as directed ,however claims still do not get paid. We are using diabetic with pvd E11.51 as a diagnosis The denials states:Bill FFS Medicaid cost share and medically unnecessary edit(mue). Medicaid will not pay these claims. When we call Healthfirst they tell us that they follow Medicare guidelines however they will not pay these claims. What can we do to get these claims paid?

Based on the context provided below, there are two reasons why diabetic shoes and inserts are being denied by Healthfirst even with prior authorization from the managed care plan. According to the Medicare LCD for therapeutic shoes for patients with diabetes:

• All line items must be appended with the -KX modifier (along with the site modifier) to show that supporting documentation is on file to justify medical necessity of the item, and
• While diabetes is one of the conditions billed for coverage, billing another systemic condition such as PVD is not acceptable- the patient needs to have another complication specific to the foot or ankle, such as flat feet, a musculoskeletal issue, bunions, corns/calluses, etc as a secondary diagnosis (there are no limitations)

In addition, a referring provider should be listed on the claim as the patient’s PCP or other specialist such as an endocrinologist who attests to the patient’s need for diabetic shoes and inserts- the podiatrist dispensing the shoes cannot be listed as the referring provider on the claim. Making the following amendments and submitting a corrected claim should adjust a denied claim to pay by Healthfirst.