07/28/2023

Healthfirst Coverage-CPT A5514

Have Healthfirst Medicare Advantage plans stopped covering diabetic multiple density shoe inserts (CPT A5514)? Despite getting an authorization and being told the benefit is covered, when billing along with CPT A5500, we have received claims back on multiple members with Healthfirst Medicare plans in which they advise us to send the full charges for A5514 to NYS Medicaid and only pay on the A5500 code. We have even tried to appeal the claims processing and we are advised by Healthfirst that they have processed the claim correctly.

Healthfirst follows Medicare guidelines for the coverage of diabetic shoes and inserts. HCPCS A5514 should be covered by the Medicare Advantage Plan as long as prior authorization has been obtained prior to the items being dispensed to the patient. FFS Medicaid should not be paying for a benefit that is the responsibility of the Medicare Advantage Plan. These denials should be either appealed or handled with the provider representative for an adjustment of the incorrectly denied DME items.