Foot Care Services

Policy ID: P-1-028

Section: Podiatry

Effective Date: November 01, 2019

Revised Date: May 13, 2025

Revision Effective Date: July 07, 2025

Last Reviewed: May 13, 2025

Applies To: Commercial and Medicaid Expansion

Description

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.

Policy Application

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.

Criteria

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;

Peripheral circulatory disorder; or
Peripheral neuropathic disease; and
ONLY when the individual is being treated for any ONE of the following diagnoses:
Amyotrophic Lateral Sclerosis (ALS); or
Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis); or
Arteritis of the feet; or
Buerger's disease; or
Carcinoma; or
Chronic indurated cellulitis; or
Chronic venus insufficiency; or
Diabetes mellitus; or
Drugs and toxins; or
Hereditary disorders such as but not limited to:
- Hereditary sensory radicular neuropathy; or
- Angiokeratoma corporis diffusum (Fabry's); or
- Amyloid neuropathy; or
Intractable edema - secondary to a specific disease (e.g., congestive heart failure (CHF), kidney disease, hypothyroidism); or
Leprosy; or
Lymphedema - secondary to a specific disease (e.g., Milroy's disease, malignancy); or
Malnutrition and vitamin deficiency malnutrition that can be as a result of but not limited to the following:
- Alcoholism malabsorption; or
- Celiac Disease; or
- Pellagra; or
- Pernicious anemia; or
- Tropical Sprue; or
Multiple Sclerosis; or
Neurosyphilis; or
Peripheral vascular disease; or
Post-phlebitic syndrome; or
Raynaud's disease; or
Stricture of artery; or
Traumatic injury; or
Uremia.

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:

- Absent posterior tibial pulse; or
- Absent dorsalis pedis pulse; or
- Advanced trophic changes; AT LEAST THREE (3) of the following are required:
  - Hair growth (decrease or absence); or
  - Nail changes (thickening); or
  - Pigmentary changes (discoloration); or
  - Skin texture (thin, shiny); or
  - Skin color (rubor or redness); or
A Class C Finding -of ONE (1) from Class B and TWO (2) from Class C:
- Claudication; or
- Temperature changes (e.g., cold feet); or
- Edema; or
- Paresthesia; or
- Burning

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:

For ambulatory individuals;

Clinical evidence of mycosis of the toenail; and
Marked limitation of ambulation, pain, or secondary infection resulting from the
thickening and dystrophy of the infected toenail plate

For non-ambulatory individuals: Clonical evidence of mycosis of the toenail; and The individual suffers from pain or secondary infection, or the condition compromises the individual's activities of daily living or care resulting from the thickening and dystrophy of the infected toenail plate.

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.

Services that do not meet the criteria as outlined in this policy are considered not medically necessary.

Procedure Codes

11720

11721

Procedure Codes

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;

Ingrown toenails
Subungual abscess; or
Complicated injury of the toes or fingers involving the nail component severe enough to require removal of the nail; or
Severe or recurrent fungal nail infection that has failed to respond to usual, less invasive treatment (for example, pharmacological treatment, debridement); or
Onychogryposis or onychauxis; or
Deformed nails that prevent wearing shoes or otherwise jeopardize the integrity of the toe.

Procedure Codes

11730

11732

11750

11765

Diagnosis Codes

Covered Diagnosis codes for Procedure Codes 11055, 11056, 11057, 11719, 11720, 11721, G0127, G0245, G0246, G0247, S0390

A30.0

A30.1

A30.2

A30.3

A30.4

A30.5

A50.1

A50.40

A50.41

A50.42

A50.43

A50.45

A52.11

A52.13

A52.14

A52.15

A52.16

A52.17

A52.19

A52.2

A52.3

B20

B35.1

D51.0

D81.818

D81.819

E08.00

E08.01

E08.10

E08.11

E08.21

E08.22

E08.29

E08.311

E08.319

E08.3211

E08.3212

E08.3213

E08.3291

E08.3292

E08.3293

E08.3311

E08.3312

E08.3313

E08.3391

E08.3392

E08.3393

E08.3411

E08.3412

E08.3413

E08.3491

E08.3492

E08.3493

E08.3511

E08.3512

E08.3513

E08.3521

E08.3522

E08.3523

E08.3531

E08.3532

E08.3533

E08.3541

E08.3542

E08.3543

E08.3551

E08.3552

E08.3553

E08.3591

E08.3592

E08.3593

E08.36

E08.37X1

E08.37X2

E08.37X3

E08.39

E08.40

E08.41

E08.42

E08.43

E08.44

E08.49

E08.51

E08.52

E08.59

E08.610

E08.618

E08.620

E08.621

E08.622

E08.628

E08.630

E08.638

E08.641

E08.649

E08.65

E08.69

E08.8

E08.9

E09.00

E09.01

E09.10

E09.11

E09.21

E09.22

E09.29

E09.311

E09.319

E09.3211

E09.3212

E09.3213

E09.3291

E09.3292

E09.3293

E09.3311

E09.3312

E09.3313

E09.3391

E09.3392

E09.3393

E09.3411

E09.3412

E09.3413

E09.3491

E09.3492

E09.3493

E09.3511

E09.3512

E09.3513

E09.3521

E09.3522

E09.3523

E09.3531

E09.3533

E09.3541

E09.3542

E09.3543

E09.3551

E09.3552

E09.3553

E09.3591

E09.3592

E09.3593

E09.36

E09.37X1

E09.37X2

E09.37X3

E09.39

E09.40

E09.41

E09.42

E09.43

E09.44

E09.49

E09.51

E09.52

E09.59

E09.610

E09.618

E09.620

E09.621

E09.622

E09.628

E09.630

E09.638

E09.641

E09.649

E09.65

E09.69

E09.8

E09.9

E10.10

E10.11

E10.21

E10.22

E10.29

E10.311

E10.319

E10.3211

E10.3212

E10.3213

E10.329

E10.3291

E10.3292

E10.3293

E10.3311

E10.3312

E10.3313

E10.3391

E10.3392

E10.3393

E10.3411

E10.3412

E10.3413

E10.3491

E10.3492

E10.3493

E10.3511

E10.3512

E10.3513

E10.3521

E10.3522

E10.3523

E10.3531

E10.3532

E10.3533

E10.3541

E10.3542

E10.3543

E10.3551

E10.3552

E10.3553

E10.3591

E10.3592

E10.3593

E10.36

E10.39

E10.40

E10.41

E10.42

E10.43

E10.44

E10.49

E10.51

E10.52

E10.59

E10.610

E10.618

E10.620

E10.621

E10.622

E10.628

E10.630

E10.638

E10.641

E10.649

E10.65

E10.69

E10.8

E10.9

E11.00

E11.01

E11.21

E11.22

E11.29

E11.311

E11.319

E11.3211

E11.3212

E11.3213

E11.3291

E11.3292

E11.3293

E11.3311

E11.3312

E11.3313

E11.3391

E11.3392

E11.3393

E11.3411

E11.3412

E11.3413

E11.3491

E11.3492

E11.3493

E11.3511

E11.3512

E11.3513

E11.3521

E11.3522

E11.3523

E11.3531

E11.3532

E11.3533

E11.3541

E11.3542

E11.3543

E11.3551

E11.3552

E11.3553

E11.3591

E11.3592

E11.3593

E11.36

E11.37X1

E11.37X2

E11.37X3

E11.39

E11.40

E11.41

E11.42

E11.43

E11.44

E11.49

E11.51

E11.52

E11.59

E11.610

E11.618

E11.620

E11.621

E11.622

E11.628

E11.630

E11.638

E11.641

E11.649

E11.65

E11.69

E11.8

E11.9

E13.00

E13.01

E13.10

E13.11

E13.21

E13.22

E13.29

E13.311

E13.319

E13.3211

E13.3212

E13.3213

E13.3291

E13.3292

E13.3293

E13.3311

E13.3312

E13.3313

E13.3391

E13.3392

E13.3393

E13.3411

E13.3412

E13.3413

E13.3491

E13.3492

E13.3493

E13.3511

E13.3512

E13.3513

E13.3521

E13.3522

E13.3523

E13.3531

E13.3532

E13.3533

E13.3541

E13.3542

E13.3543

E13.3551

E13.3552

E13.3553

E13.3591

E13.3592

E13.3593

E13.36

E13.37X1

E13.37X2

E13.37X3

E13.39

E13.40

E13.41

E13.42

E13.43

E13.44

E13.49

E13.51

E13.52

E13.59

E13.610

E13.618

E13.620

E13.621

E13.622

E13.628

E13.630

E13.638

E13.641

E13.649

E13.65

E13.69

E13.8

E13.9

E52

E53.0

E53.1

E53.8

E53.9

E75.21

E75.22

E75.240

E75.241

E75.242

E75.243

E75.244

E75.248

E75.249

E75.3

E77.0

E77.1

E77.8

E77.9

E85.1

E85.2

E85.3

E85.4

E85.81

E85.82

E85.89

E85.9

G12.21

G12.23

G12.24

G12.25

G13.0

G13.1

G35

G60.0

G60.1

G60.2

G60.3

G60.8

G60.9

G61.0

G61.1

G61.81

G61.89

G61.9

G62.0

G62.1

G62.2

G62.81

G62.82

G62.89

G62.9

G63

G64

G65.0

G65.1

G65.2

G90.09

G99.0

I70.201

I70.202

I70.203

I70.211

I70.212

I70.213

I70.221

I70.222

I70.223

I70.231

I70.232

I70.233

I70.234

I70.235

I70.238

I70.239

I70.241

I70.242

I70.243

I70.244

I70.245

I70.248

I70.25

I70.261

I70.262

I70.263

I70.291

I70.292

I70.293

I70.90

I70.91

I73.00

I73.01

I73.1

I73.81

I73.89

I73.9

I77.1

I77.6

I79.1

I79.8

I80.01

I80.02

I80.03

I80.10

I80.11

I80.12

I80.13

I80.201

I80.202

I80.203

I80.221

I80.222

I80.223

I80.229

I80.231

I80.232

I80.233

I80.239

I80.241

I80.242

I80.243

I80.291

I80.292

I80.293

I87.001

I87.002

I87.003

I87.011

I87.012

I87.013

I87.021

I87.022

I87.023

I87.031

I87.032

I87.033

I87.091

I87.092

I87.093

I87.1

I87.2

I87.301

I87.302

I87.303

I87.311

I87.312

I87.313

I87.321

I87.322

I87.323

I87.331

I87.332

I87.333

I87.391

I87.392

I87.393

I87.9

I89.0

I99.9

K90.0

K90.1

K90.9

L02.415

L02.416

L02.611

L02.612

L02.91

L03.031

L03.032

L03.041

L03.042

L03.115

L03.116

L03.125

L03.126

L03.90

L03.91

L60.0

L98.3

M05.511

M05.512

M05.521

M05.522

M05.531

M05.532

M05.541

M05.542

M05.551

M05.552

M05.561

M05.562

M05.571

M05.572

M05.59

M34.83

N18.1

N18.2

N18.30

N18.31

N18.32

N18.4

N18.5

N18.6

O24.011

O24.012

O24.013

O24.02

O24.03

O24.111

O24.112

O24.113

O24.12

O24.13

O24.311

O24.312

O24.313

O24.811

O24.812

O24.813

O24.82

O24.83

O24.911

O24.912

O24.913

O24.92

Q82.0

R60.0

R60.1

R60.9

S86.001A

S86.002A

S86.091A

S86.092A

S86.101A

S86.102A

S86.191A

S86.192A

S86.201A

S86.202A

S86.291A

S86.292A

S86.301A

S86.302A

S86.309A

S86.391A

S86.392A

S86.801A

S86.802A

S86.891A

S86.892A

S86.901A

S86.902A

S86.991A

S86.992A

S89.81XA

S89.82XA

S89.91XA

S89.92XA

S96.001A

S96.002A

S96.009A

S96.091A

S96.092A

S96.101A

S96.102A

S96.191A

S96.192A

S96.201A

S96.202A

S96.291A

S96.292A

S96.801A

S96.802A

S96.891A

S96.892A

S96.901A

S96.902A

S96.991A

S96.992A

S99.811A

S99.812A

S99.821A

S99.822A

S99.911A

S99.912A

S99.921A

S99.922A

Z79.01

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

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-21-2020 Coding update

Removed N18.3; and
Added N18.30, N18.31, N18.32; and
Updated language.

Internal Medical Policy Committee 1-19-2021 Annual Review-

Changed the lay-out of criteria,
No changes to criteria

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

Removed Diagnosis Codes I70.208, I70.209,I70.218, I70.219, I70.228, I70.229, I70.268, I70.269, I70.298, I70.299, I80.00, I80.209, I80.299, I80.3, I87.009, I87.019, I87.029, I87.039, I87.099, I87.309, I87.319, I87.329, I87.339, I87.399, L02.419, L02.619, L03.039, L03.049, L03.119, L03.129, M05.50, M05.519, M05.529, M05.539, M05.549, M05.559, M05.569, M05.579, N18.9, O24.019, O24.119, O24.319, O24.32, O24.33, O24.819, O24.919, O24.93, S86.009A, S86.099A, S86.109A, S86.199A, S86.209A, S86.299A, S86.399A, S86.809A, S86.899A, S86.909A, S86.999A, S89.80XA, S89.90XA, S96.099A, S96.109A, S96.199A, S96.209A, S96.299A, S96.909A, S96.999A, S99.819A, S99.829A, S99.919A; and
Added D iagnosis Codes A52.3, E08.00, E08.01, E08.10, E75.244, I80.241, I80.242, I80.243, and L98.3; and
Updated language throughout policy

Internal Medical Policy Committee 11-15-2023 - no changes in criteria

Internal Medical Policy Committee 11-19-2024 Annual Review-no changes in criteria

Added Policy Application

Internal Medical Policy Committee May 13, 2025 - Revision with Coding update Effective July 07, 2025.

Removed section 'Treatment of mycotic infection' and moved criteria to first section; and
Changed 'Mycotic Nails' section to 'In the absence of a systemic condition, debridement of mycotic nails'; and
Removed 97022 from covered Diagnosis Codes.

Links

References (PDF)

Disclaimer

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.

Policy ID: P-1-027

Section: Podiatry

Effective Date: November 01, 2019

Revised Date: November 15, 2024

Revision Effective Date: January 06, 2025

Last Reviewed: November 15, 2024

Archived Date: July 06, 2025

Applies To: Commercial and Medicaid Expansion

Description

Policy Application

Criteria

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;

Peripheral circulatory disorder; or
Peripheral neuropathic disease; and
ONLY when the individual is being treated for any ONE of the following diagnoses:
Amyotrophic Lateral Sclerosis (ALS); or
Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis); or
Arteritis of the feet; or
Buerger's disease; or
Carcinoma; or
Chronic indurated cellulitis; or
Chronic venus insufficiency; or
Diabetes mellitus; or
Drugs and toxins; or
Hereditary disorders such as but not limited to:
- Hereditary sensory radicular neuropathy; or
- Angiokeratoma corporis diffusum (Fabry's); or
- Amyloid neuropathy; or
Intractable edema - secondary to a specific disease (e.g., congestive heart failure (CHF), kidney disease, hypothyroidism); or
Leprosy; or
Lymphedema - secondary to a specific disease (e.g., Milroy's disease, malignancy); or
Malnutrition and vitamin deficiency malnutrition that can be as a result of but not limited to the following:
- Alcoholism malabsorption; or
- Celiac Disease; or
- Pellagra; or
- Pernicious anemia; or
- Tropical Sprue; or
Multiple Sclerosis; or
Neurosyphilis; or
Peripheral vascular disease; or
Post-phlebitic syndrome; or
Raynaud's disease; or
Stricture of artery; or
Traumatic injury; or
Uremia.

Services that do not meet the criteria as outlined in this policy are considered not medically necessary.

Procedure Codes

S0390

11719

Mycotic Nails

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.

Debridement of hypertrophic nails is limited to once every 60 days. More frequent debridement of nails is considered not medically necessary.

Procedure Codes

11720

11721

S0390

Pedicure services are non-covered.

Procedure Codes

17999

97022

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:

Systemic conditions that are significant enough to result in severe circulatory insufficiency and/or areas of desensitization in the lower extremities, that are a result of but not limited to, ANY of the following:
- Diabetes mellitus; or
- Peripheral vascular disease; or
- Peripheral neuropathy; or
Evaluation/debridement of mycotic nails, in the absence of a systemic condition, when BOTH of the following conditions are met:
- There is pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate; and
- If ambulatory, there is pain to a degree that there is difficulty walking and/or abnormality of gait.

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:
- Absent posterior tibial pulse; or
- Absent dorsalis pedis pulse; or
- Advanced trophic changes; AT LEAST THREE (3) of the following are required:
  - Hair growth (decrease or absence); or
  - Nail changes (thickening); or
  - Pigmentary changes (discoloration); or
  - Skin texture (thin, shiny); or
  - Skin color (rubor or redness); or
A Class C Finding of ONE (1) from Class B and TWO (2) from Class C:
- Claudication; or
- Temperature changes (e.g., cold feet); or
- Edema; or
- Paresthesia; or
- Burning.

Procedure Codes

11055

11056

11057

G0127

G0245

G0246

G0247

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;

Ingrown toenails
Subungual abscess; or
Complicated injury of the toes or fingers involving the nail component severe enough to require removal of the nail; or
Severe or recurrent fungal nail infection that has failed to respond to usual, less invasive treatment (for example, pharmacological treatment, debridement); or
Onychogryposis or onychauxis; or
Deformed nails that prevent wearing shoes or otherwise jeopardize the integrity of the toe.

Procedure Codes

11730

11732

11750

11765

Diagnosis Codes

Covered Diagnosis codes for procedure codes 11055, 11056, 11057, 11719, 11720, 11721, 97022, G0127, G0245, G0246, G0247, S0390

A30.0

A30.1

A30.2

A30.3

A30.4

A30.5

A50.1

A50.40

A50.41

A50.42

A50.43

A50.45

A52.11

A52.13

A52.14

A52.15

A52.16

A52.17

A52.19

A52.2

A52.3

B20

B35.1

D51.0

D81.818

D81.819

E08.00

E08.01

E08.10

E08.11

E08.21

E08.22

E08.29

E08.311

E08.319

E08.3211

E08.3212

E08.3213

E08.3291

E08.3292

E08.3293

E08.3311

E08.3312

E08.3313

E08.3391

E08.3392

E08.3393

E08.3411

E08.3412

E08.3413

E08.3491

E08.3492

E08.3493

E08.3511

E08.3512

E08.3513

E08.3521

E08.3522

E08.3523

E08.3531

E08.3532

E08.3533

E08.3541

E08.3542

E08.3543

E08.3551

E08.3552

E08.3553

E08.3591

E08.3592

E08.3593

E08.36

E08.37X1

E08.37X2

E08.37X3

E08.39

E08.40

E08.41

E08.42

E08.43

E08.44

E08.49

E08.51

E08.52

E08.59

E08.610

E08.618

E08.620

E08.621

E08.622

E08.628

E08.630

E08.638

E08.641

E08.649

E08.65

E08.69

E08.8

E08.9

E09.00

E09.01

E09.10

E09.11

E09.21

E09.22

E09.29

E09.311

E09.319

E09.3211

E09.3212

E09.3213

E09.3291

E09.3292

E09.3293

E09.3311

E09.3312

E09.3313

E09.3391

E09.3392

E09.3393

E09.3411

E09.3412

E09.3413

E09.3491

E09.3492

E09.3493

E09.3511

E09.3512

E09.3513

E09.3521

E09.3522

E09.3523

E09.3531

E09.3533

E09.3541

E09.3542

E09.3543

E09.3551

E09.3552

E09.3553

E09.3591

E09.3592

E09.3593

E09.36

E09.37X1

E09.37X2

E09.37X3

E09.39

E09.40

E09.41

E09.42

E09.43

E09.44

E09.49

E09.51

E09.52

E09.59

E09.610

E09.618

E09.620

E09.621

E09.622

E09.628

E09.630

E09.638

E09.641

E09.649

E09.65

E09.69

E09.8

E09.9

E10.10

E10.11

E10.21

E10.22

E10.29

E10.311

E10.319

E10.3211

E10.3212

E10.3213

E10.329

E10.3291

E10.3292

E10.3293

E10.3311

E10.3312

E10.3313

E10.3391

E10.3392

E10.3393

E10.3411

E10.3412

E10.3413

E10.3491

E10.3492

E10.3493

E10.3511

E10.3512

E10.3513

E10.3521

E10.3522

E10.3523

E10.3531

E10.3532

E10.3533

E10.3541

E10.3542

E10.3543

E10.3551

E10.3552

E10.3553

E10.3591

E10.3592

E10.3593

E10.36

E10.39

E10.40

E10.41

E10.42

E10.43

E10.44

E10.49

E10.51

E10.52

E10.59

E10.610

E10.618

E10.620

E10.621

E10.622

E10.628

E10.630

E10.638

E10.641

E10.649

E10.65

E10.69

E10.8

E10.9

E11.00

E11.01

E11.21

E11.22

E11.29

E11.311

E11.319

E11.3211

E11.3212

E11.3213

E11.3291

E11.3292

E11.3293

E11.3311

E11.3312

E11.3313

E11.3391

E11.3392

E11.3393

E11.3411

E11.3412

E11.3413

E11.3491

E11.3492

E11.3493

E11.3511

E11.3512

E11.3513

E11.3521

E11.3522

E11.3523

E11.3531

E11.3532

E11.3533

E11.3541

E11.3542

E11.3543

E11.3551

E11.3552

E11.3553

E11.3591

E11.3592

E11.3593

E11.36

E11.37X1

E11.37X2

E11.37X3

E11.39

E11.40

E11.41

E11.42

E11.43

E11.44

E11.49

E11.51

E11.52

E11.59

E11.610

E11.618

E11.620

E11.621

E11.622

E11.628

E11.630

E11.638

E11.641

E11.649

E11.65

E11.69

E11.8

E11.9

E13.00

E13.01

E13.10

E13.11

E13.21

E13.22

E13.29

E13.311

E13.319

E13.3211

E13.3212

E13.3213

E13.3291

E13.3292

E13.3293

E13.3311

E13.3312

E13.3313

E13.3391

E13.3392

E13.3393

E13.3411

E13.3412

E13.3413

E13.3491

E13.3492

E13.3493

E13.3511

E13.3512

E13.3513

E13.3521

E13.3522

E13.3523

E13.3531

E13.3532

E13.3533

E13.3541

E13.3542

E13.3543

E13.3551

E13.3552

E13.3553

E13.3591

E13.3592

E13.3593

E13.36

E13.37X1

E13.37X2

E13.37X3

E13.39

E13.40

E13.41

E13.42

E13.43

E13.44

E13.49

E13.51

E13.52

E13.59

E13.610

E13.618

E13.620

E13.621

E13.622

E13.628

E13.630

E13.638

E13.641

E13.649

E13.65

E13.69

E13.8

E13.9

E52

E53.0

E53.1

E53.8

E53.9

E75.21

E75.22

E75.240

E75.241

E75.242

E75.243

E75.244

E75.248

E75.249

E75.3

E77.0

E77.1

E77.8

E77.9

E85.1

E85.2

E85.3

E85.4

E85.81

E85.82

E85.89

E85.9

G12.21

G12.23

G12.24

G12.25

G13.0

G13.1

G35

G60.0

G60.1

G60.2

G60.3

G60.8

G60.9

G61.0

G61.1

G61.81

G61.89

G61.9

G62.0

G62.1

G62.2

G62.81

G62.82

G62.89

G62.9

G63

G64

G65.0

G65.1

G65.2

G90.09

G99.0

I70.201

I70.202

I70.203

I70.211

I70.212

I70.213

I70.221

I70.222

I70.223

I70.231

I70.232

I70.233

I70.234

I70.235

I70.238

I70.239

I70.241

I70.242

I70.243

I70.244

I70.245

I70.248

I70.25

I70.261

I70.262

I70.263

I70.291

I70.292

I70.293

I70.90

I70.91

I73.00

I73.01

I73.1

I73.81

I73.89

I73.9

I77.1

I77.6

I79.1

I79.8

I80.01

I80.02

I80.03

I80.10

I80.11

I80.12

I80.13

I80.201

I80.202

I80.203

I80.221

I80.222

I80.223

I80.229

I80.231

I80.232

I80.233

I80.239

I80.241

I80.242

I80.243

I80.291

I80.292

I80.293

I87.001

I87.002

I87.003

I87.011

I87.012

I87.013

I87.021

I87.022

I87.023

I87.031

I87.032

I87.033

I87.091

I87.092

I87.093

I87.1

I87.2

I87.301

I87.302

I87.303

I87.311

I87.312

I87.313

I87.321

I87.322

I87.323

I87.331

I87.332

I87.333

I87.391

I87.392

I87.393

I87.9

I89.0

I99.9

K90.0

K90.1

K90.9

L02.415

L02.416

L02.611

L02.612

L02.91

L03.031

L03.032

L03.041

L03.042

L03.115

L03.116

L03.125

L03.126

L03.90

L03.91

L60.0

L98.3

M05.511

M05.512

M05.521

M05.522

M05.531

M05.532

M05.541

M05.542

M05.551

M05.552

M05.561

M05.562

M05.571

M05.572

M05.59

M34.83

N18.1

N18.2

N18.30

N18.31

N18.32

N18.4

N18.5

N18.6

O24.011

O24.012

O24.013

O24.02

O24.03

O24.111

O24.112

O24.113

O24.12

O24.13

O24.311

O24.312

O24.313

O24.811

O24.812

O24.813

O24.82

O24.83

O24.911

O24.912

O24.913

O24.92

Q82.0

R60.0

R60.1

R60.9

S86.001A

S86.002A

S86.091A

S86.092A

S86.101A

S86.102A

S86.191A

S86.192A

S86.201A

S86.202A

S86.291A

S86.292A

S86.301A

S86.302A

S86.309A

S86.391A

S86.392A

S86.801A

S86.802A

S86.891A

S86.892A

S86.901A

S86.902A

S86.991A

S86.992A

S89.81XA

S89.82XA

S89.91XA

S89.92XA

S96.001A

S96.002A

S96.009A

S96.091A

S96.092A

S96.101A

S96.102A

S96.191A

S96.192A

S96.201A

S96.202A

S96.291A

S96.292A

S96.801A

S96.802A

S96.891A

S96.892A

S96.901A

S96.902A

S96.991A

S96.992A

S99.811A

S99.812A

S99.821A

S99.822A

S99.911A

S99.912A

S99.921A

S99.922A

Z79.01

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

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-21-2020 Coding update

Removed N18.3; and
Added N18.30, N18.31, N18.32; and
Updated language.

Internal Medical Policy Committee 1-19-2021 Annual Review-

Changed the lay-out of criteria,
No changes to criteria

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

Removed diagnosis codes I70.208, I70.209,I70.218, I70.219, I70.228, I70.229, I70.268, I70.269, I70.298, I70.299, I80.00, I80.209, I80.299, I80.3, I87.009, I87.019, I87.029, I87.039, I87.099, I87.309, I87.319, I87.329, I87.339, I87.399, L02.419, L02.619, L03.039, L03.049, L03.119, L03.129, M05.50, M05.519, M05.529, M05.539, M05.549, M05.559, M05.569, M05.579, N18.9, O24.019, O24.119, O24.319, O24.32, O24.33, O24.819, O24.919, O24.93, S86.009A, S86.099A, S86.109A, S86.199A, S86.209A, S86.299A, S86.399A, S86.809A, S86.899A, S86.909A, S86.999A, S89.80XA, S89.90XA, S96.099A, S96.109A, S96.199A, S96.209A, S96.299A, S96.909A, S96.999A, S99.819A, S99.829A, S99.919A; and
Added diagnosis codes A52.3, E08.00, E08.01, E08.10, E75.244, I80.241, I80.242, I80.243, and L98.3; and
Updated language throughout policy

Internal Medical Policy Committee 11-15-2023 - no changes in criteria

Internal Medical Policy Committee 11-19-2024 Annual Review-no changes in criteria

Added Policy Application

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