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Details on being a Medicaid Expansion provider
Routine foot care - Includes the treatment of corns, callouses, clavus, tyloma or tylomata, plantar keratosis, hyperkeratosis and keratotic lesions, bunions (except capsular or bone surgery thereof), and nails (except surgery for ingrown nails and/or debridement of symptomatic, hypertrophic nails). Treatment of these conditions may pose a hazard when performed by a non-professional person on individuals with a systemic condition that has resulted in severe circulatory embarrassment or areas of desensitization in the legs or feet.
Debridement of mycotic nails - This service is also part of routine foot care for the temporary reduction in the size or girth of an abnormal nail plate, short of avulsion. It is performed most commonly without anesthesia to: relieve pain, treat infection (bacterial, fungal, or viral), temporarily remove an anatomic deformity such as onychauxis (thickened nail), or certain types of onychocryptosis (ingrown nail), expose subungual conditions for the purpose of treatment as well as diagnosis (biopsy, culture, etc.), prevent further problems, such as subungual ulceration in an insensate individual with onychauxis.
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date; and/or
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.
Coverage is subject to the specific terms of the member's benefit plan.
When the benefit exists professional treatment of corns, callouses, clavus, tyloma or tylomata, plantar keratosis, hyperkeratosis and keratotic lesions, mycotic nails, bunions (except capsular or bone surgery thereof), and nails (except surgery for ingrown nails and/or debridement of symptomatic, hypertrophic nails) may be considered medically necessary if the individual has;
The individual must also meet ONE of the following:
A Class A Finding - of a non-traumatic amputation of foot or integral skeleton portion thereof; or A Class B Finding - of AT LEAST TWO (2) of the following:
Services that do not meet the criteria as outlined in this policy are considered not medically necessary.
Procedure Codes
11055
11056
11057
11719
G0127
G0245
G0246
G0247
S0390
In the absence of a systemic condition, debridement of mycotic nails is considered medically necessary when one or more of the following conditions is met:
Laser treatment of onychomycosis (mycotic nail) is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Debridement of hypertrophic nails is limited to once every 60 days. More frequent debridement of nails is considered not medically necessary.
17999
97022
Surgical treatment of the nail that is out of the scope of routine foot care may be considered medically necessary for ANY of the following conditions;
11730
11732
11750
11765
Covered Diagnosis codes for Procedure Codes 11055, 11056, 11057, 11719, 11720, 11721, G0127, G0245, G0246, G0247, S0390
Covered Diagnosis codes for procedure codes 11730, 11732, 11750, and 11765
B35.1
L03.031
L03.032
L40.0
L40.1
L40.2
L40.3
L40.4
L40.8
L60.0
L60.1
L60.2
L60.3
L60.4
L60.5
L60.8
L62
Q84.3
Q84.4
Q84.5
Q84.6
S61.101A
S61.101D
S61.101S
S61.102A
S61.102D
S61.102S
S61.111A
S61.111D
S61.111S
S61.112A
S61.112D
S61.112S
S61.121A
S61.121D
S61.121S
S61.122A
S61.122D
S61.122S
S61.131A
S61.131D
S61.131S
S61.132A
S61.132D
S61.132S
S61.141A
S61.141D
S61.141S
S61.142A
S61.142D
S61.142S
S61.151A
S61.151D
S61.151S
S61.152A
S61.152D
S61.152S
S91.201A
S91.201D
S91.201S
S91.202A
S91.202D
S91.202S
S91.204A
S91.204D
S91.204S
S91.205A
S91.205D
S91.205S
S91.211A
S91.211D
S91.211S
S91.212A
S91.212D
S91.212S
S91.214A
S91.214D
S91.214S
S91.215A
S91.215D
S91.215S
S91.221A
S91.221D
S91.221S
S91.222A
S91.222D
S91.222S
S91.224A
S91.224D
S91.224S
S91.225A
S91.225D
S91.225S
S91.231A
S91.231D
S91.231S
S91.232A
S91.232D
S91.232S
S91.234A
S91.234D
S91.234S
S91.235A
S91.235D
S91.235S
S91.241A
S91.241D
S91.241S
S91.242A
S91.242D
S91.242S
S91.244A
S91.244D
S91.244S
S91.245A
S91.245D
S91.245S
S91.251A
S91.251D
S91.251S
S91.252A
S91.252D
S91.252S
S91.254A
S91.254D
S91.254S
S91.255A
S91.255D
S91.255S
T25.331A
T25.331D
T25.331S
T25.332A
T25.332D
T25.332S
T25.731A
T25.731D
T25.731S
T25.732A
T25.732D
T25.732
S61.300A
S61.300D
S61.300S
S61.301A
S61.301D
S61.301S
S61.302A
S61.302D
S61.302S
S61.303A
S61.303D
S61.303S
S61.304A
S61.304D
S61.304S
S61.305A
S61.305D
S61.305S
S61.306A
S61.306D
S61.306S
S61.307A
S61.307D
S61.307S
S61.310A
S61.310D
S61.310S
S61.311A
S61.311D
S61.311S
S61.312A
S61.312D
S61.312S
S61.313A
S61.313D
S61.313S
S61.314A
S61.314D
S61.314S
S61.315A
S61.315D
S61.315S
S61.316A
S61.316D
S61.316S
S61.317A
S61.317D
S61.317S
S61.320A
S61.320D
S61.320S
S61.321A
S61.321D
S61.321S
S61.322A
S61.322D
S61.322S
S61.323A
S61.323D
S61.323S
S61.324A
S61.324D
S61.324S
S61.325A
S61.325D
S61.325S
S61.326A
S61.326D
S61.326S
S61.327A
S61.327D
S61.327S
S61.330A
S61.330D
S61.330S
S61.331A
S61.331D
S61.331S
S61.332A
S61.332D
S61.332S
S61.333A
S61.333D
S61.333S
S61.334A
S61.334D
S61.334S
S61.335A
S61.335D
S61.335S
S61.336A
S61.336D
S61.336S
S61.337A
S61.337D
S61.337S
S61.340A
S61.340D
S61.340S
S61.341A
S61.341D
S61.341S
S61.342A
S61.342D
S61.342S
S61.343A
S61.343D
S61.343S
S61.344A
S61.344D
S61.344S
S61.345A
S61.345D
S61.345S
S61.346A
S61.346D
S61.346S
S61.347A
S61.347D
S61.347S
S61.350A
S61.350D
S61.350S
S61.351A
S61.351D
S61.351S
S61.352A
S61.352D
S61.352S
S61.353A
S61.353D
S61.353S
S61.354A
S61.354D
S61.354S
S61.355A
S61.355D
S61.355S
S61.356A
S61.356D
S61.356S
S61.357A
S61.357D
S61.357S
S90.211A
S90.211D
S90.211S
S90.212A
S90.212D
S90.212S
S90.221A
S90.221D
S90.221S
S90.222A
S90.222D
S90.222S
Not Applicable
Internal Medical Policy Committee 9-21-2020 Coding update
Internal Medical Policy Committee 1-19-2021 Annual Review-
Internal Medical Policy Committee 1-20-2022 Annual Review-no changes in criteria
Internal Medical Policy Committee 3-23-2022 Coding Update- Effective April 1, 2022 o Added Procedure Codes 11719; and G0247
Internal Medical Policy Committee 1-26-2023 Revision with Coding update - Effective March 06, 2023
Internal Medical Policy Committee 11-15-2023 - no changes in criteria
Internal Medical Policy Committee 11-19-2024 Annual Review-no changes in criteria
Internal Medical Policy Committee May 13, 2025 - Revision with Coding update Effective July 07, 2025.
References (PDF)
Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date
When the benefit exists professional treatment of corns, callouses, clavus, tyloma or tylomata, plantar keratosis, hyperkeratosis and keratotic lesions, bunions (except capsular or bone surgery thereof), and nails (except surgery for ingrown nails and/or debridement of symptomatic, hypertrophic nails) may be considered medically necessary if the individual has;
When the benefit exists, debridement of mycotic nails is considered routine foot care and may be considered medically necessary when above criterial is met.
Hypertrophic (Non-Mycotic) Nails When the benefit exists, debridement of symptomatic hypertrophic (non-mycotic) nails may be considered medically necessary.
11720
11721
Pedicure services are non-covered.
Treatment of a mycotic infection that is out of the scope of routine foot care or capsular/bone surgery, and/or debridement of non-symptomatic hypertrophic nails, may be considered medically necessary when the following criteria have been met:
Covered Diagnosis codes for procedure codes 11055, 11056, 11057, 11719, 11720, 11721, 97022, G0127, G0245, G0246, G0247, S0390
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