| Highmark Commercial Medical Policy - Pennsylvania |
| Medical Policy: | P-1-018 |
| Topic: | Coverage Requirements for Routine Foot Care and Debridement of Mycotic/Hypertrophic Nails |
| Section: | Podiatry |
| Effective Date: | May 30, 2016 |
| Issue Date: | July 18, 2016 |
| Last Reviewed: | January 2016 |
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 patients 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 patient with onychauxis. |
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
| Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
When the benefit exists and the patient 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 patient is being treated for ANY ONE of the following diagnoses:
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.
Laser treatment of onychomycosis (mycotic nail) is considered experimental/investigational due to unproven efficacy and safety and therefore is non-covered.
Whirlpool treatment performed before routine foot care to soften the nails or skin is not eligible for separate reimbursement.
Pedicure services are not covered.
Treatment of a mycotic infection that is out of the scope of routine foot care or capsular/ bone surgery, surgery for ingrown nails, and/or debridement of non-symptomatic hypertrophic nails, may be considered medically necessary when the following criteria have been met:
The patient must also meet ONE of the following:
The following modifiers are to be used with the following procedure codes: 11055, 11056, 11057, 11719, 11720, 11721 or G0127.
Submitting claims using Q7, Q8, or Q9 modifiers indicates the findings related to the patient’s condition. Failure to provide documentation supporting the use of the Q modifiers on any claim may result in denial of that claim.
| Place of Service: Inpatient/Outpatient |
Experimental/Investigational (E/I) services are not covered regardless of place of service.
| The policy position applies to all commercial lines of business |
| FEP Guidelines |
FEP covers routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes. |
| Denial Statements |
Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
A network provider can bill the member for the non-covered service.
| Links |
03/2016, Medically Necessary Modifiers Added to Coverage Requirements for Routine Foot Care and Debridement of Mycotic/Hypertrophic Nails