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: (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.

Criteria

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:

• Amyotrophic lateral sclerosis (ALS); or 
• Arteriosclerosis obliterans (ASO), arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis); or 
• Arteritis of the feet; or
• Buerger’s disease; or 
• Carcinoma; or 
• Chronic indurated cellulitis; or 
• Chronic venous 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.
• 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.
• 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 of this policy will be considered not medically necessary.

Procedure Codes

Mycotic Nails
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.

Procedure Codes

Laser treatment of onychomycosis (mycotic nail) is considered experimental/investigational and therefore is non-covered due to unproven efficacy and safety.

Procedure Codes

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:

• 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.
• 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).
• 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

The following modifiers are to be used with the following procedure codes: 11055, 11056, 11057, 11719, 11720, 11721 or G0127.

• Q7 – One (1) Class A finding.
• Q8 – Two (2) Class B findings.
• Q9 – One (1) Class B and two (2) Class C findings.

Submitting claims using Q7, Q8, or Q9 modifiers indicates the findings related to the individual’s condition. Failure to provide documentation supporting the use of the Q modifiers on any claim may result in denial of that claim.

Procedure Codes

Surgical treatment of the nail that is out of the scope of routine foot care may be considered medically necessary for the following conditions;

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

Procedure Codes

Diagnosis Codes

Covered DX codes for procedure codes 11055, 11056, 11057, 11720, 11721, 97022, G0127, G0245, G0246, S0390 

Covered Dx codes for procedure codes 11730, 11732, 11750 and 11765