CMS Pub. 100-03, ch. 1, § 70.2.1

Sensory Neuropathy with Loss of Protective Sensation (aka Diabetic

Peripheral Neuropathy)

(Rev. 1, 10-03-03)

CIM 50-8.1

Presently, peripheral neuropathy, or diabetic sensory neuropathy, is the most common

factor leading to amputation in people with diabetes. In diabetes, sensory neuropathy is

an anatomically diffuse process primarily affecting sensory and autonomic fibers;

however, distal motor findings may be present in advanced cases. Long nerves are

affected first, with symptoms typically beginning insidiously in the toes and then

advancing proximally. This leads to loss of protective sensation (LOPS), whereby a

person is unable to feel minor trauma from mechanical, thermal, or chemical sources.

When foot lesions are present, the reduction in autonomic nerve functions may also

inhibit wound healing.

Diabetic sensory neuropathy with LOPS is a localized illness of the feet and falls within

the regulation’s exception to the general exclusionary rule (see 42 CFR 411.15(l)(1)(i)).

Foot exams for people with diabetic sensory neuropathy with LOPS are reasonable and

necessary to allow for early intervention in serious complications that typically afflict

diabetics with the disease.

Effective for services furnished on or after July 1, 2002, Medicare covers, as a physician

service, an evaluation (examination and treatment) of the feet no more often than every

six months for individuals with a documented diagnosis of diabetic sensory neuropathy

and LOPS, as long as the beneficiary has not seen a foot care specialist for some other

reason in the interim. LOPS shall be diagnosed through sensory testing with the 5.07

monofilament using established guidelines, such as those developed by the National

Institute of Diabetes and Digestive and Kidney Diseases guidelines. Five sites should be

tested on the plantar surface of each foot, according to the National Institute of Diabetes

and Digestive and Kidney Diseases guidelines. The areas must be tested randomly since

the loss of protective sensation may be patchy in distribution, and the patient may get

clues if the test is done rhythmically. Heavily callused areas should be avoided. As

suggested by the American Podiatric Medicine Association, an absence of sensation at

two or more sites out of 5 tested on either foot when tested with the 5.07 Semmes-Weinstein monofilament must be present and documented to diagnose peripheral

neuropathy with loss of protective sensation.

The examination includes:

1. A patient history, and

2. A physical examination that must consist of at least the following elements:

• Visual inspection of forefoot and hindfoot (including toe web spaces);

• Evaluation of protective sensation;

• Evaluation of foot structure and biomechanics;

• Evaluation of vascular status and skin integrity;

• Evaluation of the need for special footwear; and

3 Patient education.

A. Treatment includes, but is not limited to:

• Local care of superficial wounds;

• Debridement of corns and calluses; and

• Trimming and debridement of nails.

The diagnosis of diabetic sensory neuropathy with LOPS should be established and

documented prior to coverage of foot care. Other causes of peripheral neuropathy should

be considered and investigated by the primary care physician prior to initiating or

referring for foot care for persons with LOPS.