All Policies and Precertification
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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: (1) relieve pain; (2) treat infection (bacterial, fungal, or viral); (3) temporarily remove an anatomic deformity such as onychauxis (thickened nail), or certain types of onychocryptosis (ingrown nail); (4) expose subungual conditions for the purpose of treatment as well as diagnosis (biopsy, culture, etc.); (5) prevent further problems, such as subungual ulceration in an insensate individual with onychauxis.
When the benefit exists and theindividualhas a peripheral circulatory disorder or peripheral neuropathic disease, 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 ONLY when the individual is being treated for any ONE of the following diagnoses:
Services that do not meet the criteria of this policy will be considered not medically necessary.
When the benefit exists, debridement of mycotic nails is considered routine foot care and may be considered medically necessary when above criteria is met.
Hypertrophic (Non-Mycotic) Nails
When the benefit exists, debridement of symptomatic hypertrophic (non-mycotic) nails may be considered medically necessary.
Debridement of hypertrophic nails is limited to once every 60 days. More frequent debridement of nails is considered not medically necessary.
Laser treatment of onychomycosis (mycotic nail) is considered experimental/investigational and therefore is non-covered due to unproven efficacy and safety.
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:
Theindividual must also meet ONE of the following:
Surgical treatment of the nail that is out of the scope of routine foot care may be considered medically necessary for the following conditions;
Covered DX codes for procedure codes 11055, 11056, 11057, 11720, 11721, 97022, G0127, G0245, G0246, S0390
Covered Diagnosis codes for procedure codes 11730; 11732; 11750; and 11765
Internal Medical Policy Committee 9-21-2020 Coding update removed N18.3 and added N18.30, N18.31 and N18.32; updated language.
Internal Medical Policy Committee 1-19-2021 Annual Review-changed the lay-out of criteria, no changes to criteria
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.
When the benefit exists and the individual has a peripheral circulatory disorder or peripheral neuropathic disease, 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 ONLY when the individual is being treated for ANY ONE of the following diagnoses:
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Fargo, North Dakota 58121
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