Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 01|01|2023 POLICY LAST UPDATED: 09|07|2023

OVERVIEW This policy addresses routine and non-routine foot care, nail debridement, and examination of the feet.
Non-Routine foot care includes the cutting or removal of corns and calluses, clipping, trimming, or debridement of nails, including debridement of mycotic nails, shaving, paring, cutting or removal of keratoma, tyloma, and heloma. Also included are non-definitive simple, palliative treatments like shaving or paring of plantar warts, which do not require thermal or chemical cautery and curettage. Non-routine foot care occurs when there is a localized illness, injury, or symptoms involving the foot.
Routine foot care includes hygienic and preventive maintenance care in the realm of self-care, such as cleaning and soaking the feet and the use of skin creams to maintain skin tone of both ambulatory and bedridden patients or any services performed in the absence of localized illness, injury, or symptoms involving the foot.

Note: With the exception of the use of the qualifying modifiers, Blue Cross & Blue Shield of Rhode Island follows the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations (NCD and LCD) Routine Foot Care Policy for both Medicare Advantage Plans and Commercial Products.

MEDICAL CRITERIA Not applicable

PRIOR AUTHORIZATION Not applicable

POLICY STATEMENT
Non-Routine Foot Care Non-routine foot care is covered when the patient has a systemic disease, such as metabolic, neurologic, or peripheral vascular disease, of sufficient severity that performance of such services by a nonprofessional person would put the patient at risk (for example, a systemic condition that has resulted in severe circulatory embarrassment or areas of desensitization in the patient’s legs or feet).

Routine Foot Care All other indications not addressed above as non-routine foot care are considered routine and are not covered for Medicare Advantage Plans and Commercial Products.

COVERAGE Benefits vary between groups/contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable surgery services, not covered services and the related exclusions in the podiatrist services section.

BACKGROUND Routine foot care is typically rendered when the patient has a systemic disease, such as metabolic, neurologic, or peripheral vascular disease, of sufficient severity that performance of such services by a nonprofessional person would put the patient at risk (for example, a systemic condition that has resulted in severe circulatory embarrassment or areas of desensitization in the patient’s legs or feet).

Payment Policy | Foot Care and Nail Debridement

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

Routine foot care includes the cutting or removal of corns and calluses, clipping, trimming, or debridement of nails, including debridement of mycotic nails, shaving, paring, cutting, or removal of keratoma, tyloma, and heloma. Non-definitive simple, palliative treatments include shaving or paring of plantar warts that do not require thermal or chemical cautery and curettage, other hygienic and preventive maintenance care in the realm of self care, such as cleaning and soaking the feet and the use of skin creams to maintain skin tone of both ambulatory and bedridden patients. Also included are any services performed in the absence of localized illness, injury, or symptoms involving the foot.

Podiatric physicians may establish diagnoses (care plan by an allopathic/osteopathic physician is not a coverage or medical necessity requirement) but may be part of appropriate medical care.

The criteria below outlines the specific conditions for coverage of routine foot care when the following physical and clinical findings meet the guidelines (qualifying and class findings) and are documented in the medical record.

Treatment of mycotic nails is medically necessary based on the class findings, outlined below, or the presence of qualifying systemic illnesses causing a peripheral neuropathy, is present and documented in the medical record.

In the absence of a systemic condition, the following criteria must be met: • In the case of ambulatory patients there exists: o Clinical evidence of mycosis of the toenail, and o Marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

• In the case of non-ambulatory patients there exists: o Clinical evidence of mycosis of the toenail, and o The patient suffers from pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

In addition, procedures for treating toenails are covered for one the following: • Onychogryphosis
• Onychauxis

Indications of Severe Peripheral Involvement The following physical and clinical findings, which are indicative of severe peripheral involvement, must be documented and maintained in the patient record, in order for routine foot care services to be reimbursable. Class A findings • Non-traumatic amputation of foot or integral skeletal portion thereof. Class B findings • Absent posterior tibial pulse; • Advanced trophic changes such as (three required): • hair growth (decrease or absence); • nail changes (thickening); • pigmentary changes (discoloration); • skin texture (thin, shiny); • skin color (rubor or redness) • Absent dorsalis pedis pulse.

Class C findings • Claudication; • Temperature changes (e.g., cold feet); • Edema;

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

• Paresthesias (abnormal spontaneous sensations in the feet); and • Burning.

The coverage for routine foot care may be applied when the physician rendering the routine foot care has identified one of the following:

1. A Class A finding;
2. Two of the Class B findings; or

3. One Class B and two Class C findings.

   Note: Benefits for routine foot care are also available for patients with peripheral neuropathy involving the feet, but without the vascular impairment outlined in Class B findings. The neuropathy should be of such severity that care by a nonprofessional person would put the patient at risk. If the patient has evidence of neuropathy but no vascular impairment, the use of class findings modifiers is not necessary

   Definitions
   Routine foot care: The following services are considered to be components of routine foot care, regardless of the provider rendering the service: • The cutting or removal of corns and calluses; • Clipping, trimming, or debridement of nails, including debridement of mycotic nails; • Shaving, paring, cutting or removal of keratoma, tyloma, and heloma; • Non-definitive simple, palliative treatments like shaving or paring of plantar warts which do not require thermal or chemical cautery and curettage; • Other hygienic and preventive maintenance care, such as cleaning and soaking the feet, the use of skin creams to maintain skin tone of either ambulatory or bedfast patients, and any other service performed in the absence of localized illness, injury, or symptoms involving the foot.

   Nail debridement: the significant reduction in the thickness and length of the toenail with the aim of allowing the patient to ambulate without pain. Nail debridement is a distinct service from “routine foot care.” Simple trimming of the end of the toenails by cutting or grinding is not debridement. Reduction in the length of normal or thickened elongated toenails (whether done with an electric burr or by hand) is not debridement.
   Similarly, buffing the surface or the edges of manually trimmed mycotic toenails (mycotic=fungal infection) is not debridement.

   Loss of protective sensation (LOPS): A diagnosis of diabetic sensory neuropathy with loss of protective sensation(LOPS) requires early intervention to prevent serious complications that typically afflict diabetics with sensory neuropathy. Patients with this diagnosis may receive two-foot evaluations, no more often than every six months (examination and treatment) per year, specifically for diabetic peripheral neuropathy with LOPS, as long as they have not seen a foot care professional for another reason.

   It is not necessary that an osteopathic (DO) or allopathic (MD) physician have established a diagnosis of LOPS and comprehensive diabetic care plan. However, the podiatric professional (i.e., Doctor of Podiatric Medicine) should take appropriate steps for care coordination and promotion of appropriate diabetic care with the physician who is managing the patient’s diabetes.

   Peripheral neuropathy: peripheral neuropathy involving the feet, but without the vascular impairment outlined in Class B findings. The neuropathy would be of such severity that care by a non-professional person would put the patient at risk. If the patient has evidence of neuropathy but no vascular impairment, the use of class findings modifiers is not necessary.

   Onychogryphosis: a long-standing thickening, in which typically a curved hooked nail (ram’s horn nail) occurs, and there is marked limitation of ambulation pain and/or secondary infection where the nail plate is causing symptomatic indentation of or minor laceration of the affected distal toe.

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

Onychauxis: a thickening (hypertrophy) of the base of the nail/nail bed and there is marked limitation of ambulation pain and/or secondary infection that causes symptoms.

CODING Medicare Advantage Plans and Commercial Products The following CPT codes are covered when submitted with 1 of the diagnosis codes found in group 1 of the covered diagnosis list, below. All other indications are not covered.

11055: Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion 11056: Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); 2 to 4 lesions 11057: Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); more than 4 lesions 11719: Trimming of nondystrophic nails, any number 11720: Debridement of nail(s) by any method(s); 1 to 5 11721: Debridement of nail(s) by any method(s); 6 or more G0127: Trimming of dystrophic nails, any number

The following CPT codes are covered when submitted with 1 primary and 1 secondary diagnosis code found in group 2 of the covered diagnosis list, below. All other indications are not covered.

11719: Trimming of nondystrophic nails, any number 11720: Debridement of nail(s) by any method(s); 1 to 5 11721: Debridement of nail(s) by any method(s); 6 or more G0127: Trimming of dystrophic nails, any number

Foot Care Covered Diagnosis List

RELATED POLICIES None PUBLISHED Provider Update, February 2023 Provider Update, November 2022 Provider Update, April 2022 Provider Update, April 2021 Provider Update, March 2021 Provider Update, July 2019

REFERENCES

1. CMSMedicareBenefitPolicyManual:https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/bp102c15.pdfNGSLCD Routine Foot Care & Nail Debridement: www.ngsmedicare.com
2. NationalGovernmentServices(NGS)Calulator: https://www.ngsmedicare.com/gs/portal/ngsmedicare/newngs/home-lob/pages/calculators/podiatry-calculator/

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 5 (401) 274-4848 WWW.BCBSRI.COM

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This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS