Subject:
Foot Care Services
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Foot care services include, but are not limited to, paring or cutting of benign hyperkeratotic lesions of the foot (e.g., corns, calluses), and trimming or debridement of toenails.
Debridement of toenails is the removal of nail substance, partial or complete, when the presence of such structures is causing local pathology. It is a temporary reduction in the size or girth of an abnormal nail plate, short of avulsion.
A qualified medical provider of foot care services is one who is licensed and is performing within the scope of licensure.
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
- Paring or cutting of benign hyperkeratotic lesions of the foot (e.g., corns, calluses) and trimming or debridement of toenails are usually performed by non-medical professional members and do not require the skills of a qualified medical provider of foot care services, and as such, are generally considered not medically necessary.
- For members in whom paring or cutting of corns and calluses, or trimming of toenails would be hazardous when performed by non-medical professional members, it is considered medically necessary when the following criteria are met:
- the service is performed by a qualified medical provider of foot care services; and
- the member has a systemic condition which may result in severe circulatory embarrassment (compromise) or diminished sensation in the feet, including, but not limited to, the following:
- diabetes mellitus (with or without complications);
- arteriosclerosis obliterans and peripheral vascular disease;
- Buerger’s disease;
- Chronic thrombophlebitis;
- Neuropathies involving the feet which may be associated with:
- diabetes mellitus
- pernicious anemia
- uremia
- multiple sclerosis
- hereditary sensory radicular neuropathy
- malabsorption
- leprosy and neurosyphilis
- amyloid neuropathy
- pellagra.
- Additionally, debridement of toenails is considered medically necessary when the following criteria are met:
- the service is performed by a qualified medical provider of foot care services; and
- the member has clinical evidence of any one of the following conditions:
- onychomycosis (mycotic nails) confirmed by positive culture or by documented signs and symptoms; or
- onychauxis (club nail), onychogryphosis (deformed nail), or onogryphosis (thickened nail) associated with infection or pain from gross distortions of the nail.
Medicare Coverage:
There is no National Coverage Determination (NCD) for Foot Care Services. However, per National Coverage Determination (NCD) for Services Provided for the Diagnosis and Treatment of Diabetic Sensory Neuropathy with Loss of Protective Sensation (aka Diabetic Peripheral Neuropathy) (70.2.1), routine foot care is covered when the patient has a systemic condition resulting in severe circulatory embarrassment or areas of desensitization in the legs or feet and the appropriate class findings are supported in the medical record and reported.
The evaluation (examination and treatment) of the feet as a physician service will be covered no more often than every six months for individuals with a documented diagnosis of diabetic sensory neuropathy and loss of protective sensation (LOPS), as long as the beneficiary has not seen a foot care specialist for some other reason in the interim.
Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has determined that routine foot care is covered when L35138 and L35013.criteria are met. Please refer to the below NCD and LCDs for eligibility and coverage.
LCD Routine Foot Care L35138. Available at: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00024370&_afrLoop=555431942855090#!%40%40%3F_afrLoop%3D555431942855090%26centerWidth%3D100%2525%26contentId%3D00024370%26leftWidth%3D0%2525%26rightWidth%3D0%2525%26showFooter%3Dfalse%26showHeader%3Dfalse%26_adf.ctrl-state%3Dlpfblq81o_21
LCD Debridement of Mycotic Nails L35013. Available at: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00024370&_afrLoop=555431942855090#!%40%40%3F_afrLoop%3D555431942855090%26centerWidth%3D100%2525%26contentId%3D00024370%26leftWidth%3D0%2525%26rightWidth%3D0%2525%26showFooter%3Dfalse%26showHeader%3Dfalse%26_adf.ctrl-state%3Dlpfblq81o_21
National Coverage Determination (NCD) for Services Provided for the Diagnosis and Treatment of Diabetic Sensory Neuropathy with Loss of Protective Sensation (aka Diabetic Peripheral Neuropathy) (70.2.1). Available to be accessed at CMS National Coverage Determinations (NCDs) Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx.
Local Coverage Article: Billing and Coding: Routine Foot Care (A52996). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36711&ver=18&name=314*1&UpdatePeriod=749&bc=AAAAEAAAAAAAAA%3d%3d&.
Local Coverage Article: Billing and Coding: Debridement of Mycotic Nails (A56640). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36711&ver=18&name=314*1&UpdatePeriod=749&bc=AAAAEAAAAAAAAA%3d%3d&.
Local Coverage Determination (LCD):Surgical Treatment of Nails (L34887). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36711&ver=18&name=314*1&UpdatePeriod=749&bc=AAAAEAAAAAAAAA%3d%3d&.
Local Coverage Article: Billing and Coding: Surgical Treatment of Nails (A52998). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36711&ver=18&name=314*1&UpdatePeriod=749&bc=AAAAEAAAAAAAAA%3d%3d&.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE-SNP Coverage:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Foot Care Services
Calluses, Paring
Corns, Paring
Debridement of Toenails
Nails, Trimming and Debridement
Paring of Corns and Calluses
Toenails, Trimming and Debridement
Trimming of Toenails
References:
1. American Diabetes Association. Preventive Foot Care in People With Diabetes. Diabetes Care 2002 Jan;25(1):S69-S70.
2. National Guideline Clearinghouse. Preventive foot care in people with diabetes. Release 1999; Reviewed January 2002; Republished January 2002.
3. Ronnemaa T, Hamalainen H, Toikka T, et al. Evaluation of the impact of podiatrist care in the primary prevention of foot problems in diabetic subjects. Diabetes Care 1997 Dec;20(12):1833-1837.
4. Mayfield JA, Reiber GE, Sanders LJ, et al. Preventive foot care in people with diabetes. Diabetes Care 1998 Dec;21 (12):2161-2177.
5. Frykberg RG. The team approach in diabetic foot management. Adv Wound Care 1998 Mar-Apr;11(2):71-77.
6. Strauss MB, Hart JD, Winant DM. Preventive foot care. A user-friendly system for patients and physicians. Postgrad Med 1998 May;103(5):233-236, 239-240, 245.
7. O’Hare A, Johansen K. Lower-extremity peripheral arterial disease among patients with end-stage renal disease. J Am Soc Nephrol 2001 Dec;12(12):2838-2847.
8. Highmark Medicare Services, Inc. LCD for Routine Foot Care (L27486). Effective Date: 07/11/2008.
9. Highmark Medicare Services. Inc. LCD for Debridement of Mycotic Nails (L27487). Effective Date: 07/11/2008.
10. Waibel J, Wulkan AJ, Rudnick A. Prospective efficacy and safety evaluation of laser treatments with real-time temperature feedback for fungal onychomycosis. J Drugs Dermatol. 2013 Nov 1;12(11):1237-42.
11. Gupta AK, Simpson FC. Laser therapy for onchycomycosis. J Cutan Med Surg. 2013 Oct 1;17(5):301-7.
12. American Diabetes Association. Standards of Medical Care in Diabetes-2013. Available at http://care.diabetesjournals.org/content/36/Supplement_1/S11.full
13. Flint WW, Cain JD. Nail and skin disorders of the foot. Med Clin North Am 2014 Mar;98(2):213-25.
14. Hashmi F, Nester CJ, Wright CR, et al. The evaluation of three treatments for plantar callus: a three-armed randomised, comparative trial using biophysical outcomes measures. Trials 2016 May 17;17(1):251.
15. McCulloch DK. Evaluation of the diabetic foot. In: UpToDate, Nathan DM, Mulder JE, Waltham, MA. (Accessed on 05/08/2017.)
16. McCulloch DK. Evaluation of the diabetic foot. In: UpToDate, Nathan DM, Mulder JE, Waltham, MA. (Accessed on 10/05/2018.)
17. Wexler DJ. Evaluation of the diabetic foot. In: UpToDate, Nathan DM, Mulder JE, Waltham, MA. (Accessed on 10/01/2019.)
18. Wexler DJ. Evaluation of the diabetic foot. In: UpToDate, Nathan DM, Mulder JE, Waltham, MA. (Accessed on 08/19/2020)
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
11055
11056
11057
11719
11720
11721
11730
11732
HCPCS
G0127
G0245
G0246
G0247
S0390
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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