Summary Of Evidence

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Analysis of Evidence

N/A

Please refer to CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 290 Foot Care for indications and limitations in coverage for treatment of mycotic nails.

Covered Indications

Medicare will consider the treatment of fungal (mycotic) infection of the nails a covered service when the medical record substantiates:

• Clinical evidence of mycosis of the nail, by generally accepted clinical findings such as discoloration, onycholysis, subungual debris, thickening, or secondary skin infection;

In addition one of the following must be documented for mycotic toenails:

• the ambulatory patient has marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate(s); or
• the non-ambulatory patient suffers from pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate(s).

Appropriate anti-fungal treatment is necessary to qualify nail debridement as a medically necessary and reimbursable service unless contraindicated. If an anti-fungal treatment is not used, the contraindication must be documented in the medical record.

Patients need not have an underlying systemic condition to be covered for mycotic nail care.

Limitations

As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.