LCD L37643

Coverage Guidance

Title XVIII of the Social Security Act, §1862 (a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862 (a)(13)(C) defines the exclusion for payment of routine foot care.

42 CFR Section 411.15 (l) Particular services excluded from coverage.

CMS Internet- Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §290 Foot Care

CMS Internet- Only Manual, Pub 100-03, Medicare National Coverage Determination Manual, Chapter 1, §70.2.1 Services Provided for the Diagnosis and Treatment of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (aka Diabetic Peripheral Neuropathy)

Indications and Limitations of Coverage

Background

Generally, routine foot care is excluded from coverage. Services that normally are considered routine and not covered by Medicare include the following, regardless of the provider rendering the service:

• Cutting or removal of corns and calluses;

• Trimming, cutting, clipping 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 in the realm of self care, such as cleaning and soaking the feet, the use of skin creams to maintain skin tone of either ambulatory or bedfast patients;

• Any other service performed in the absence of localized illness, injury or symptoms involving the foot.

There are exceptions to routine foot care exclusions. This local coverage determination (LCD) outlines such exceptions.

Indications

Routine foot care services are subject to national regulation, which provides definitions, indications and limitations for Medicare payment of routine foot care services.

Exceptions to routine foot care exclusions include:

• Routine foot care that is necessary and an integral part of an otherwise covered service;

• Treatment of warts on foot;

• The presence of systemic conditions, such as metabolic, neurologic, or peripheral vascular disease;

• Mycotic nails:

• In the presence of systemic conditions as noted above in #3.

• In the absence of systemic conditions:

• An ambulatory patient must have marked limitation of ambulation, pain or secondary infection resulting from the thickening and dystrophy of infected toenail plate.

• A non-ambulatory patient suffers from pain or secondary infection resulting from the thickening and dystrophy of an infected toenail plate.

Presumption of Coverage

In evaluating whether the routine services can be reimbursed, a presumption of coverage may be made where the evidence available discloses certain physical and/or clinical findings consistent with the diagnosis and indicative of severe peripheral involvement. For purposes of applying this presumption the following findings are pertinent:

Class A Findings

• Nontraumatic amputation of foot or integral skeletal portion thereof.

Class B Findings

• Absent posterior tibial pulse;

• Advanced trophic changes as: hair growth (decrease or absence), nail changes (thickening), pigmentary changes (discoloration), skin texture (thin, shiny), skin color (rubor or redness) (three required) and;

• Absent dorsalis pedis pulse.

Class C Findings

• Claudication;

• Temperature changes (e.g., cold feet);

• Edema;

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

• Burning.

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

• One Class A finding;

• Two of the Class B findings; or

• One Class B and two Class C findings.

Limitations

1.Covered exceptions to routine foot care services are considered medically necessary once (1) in 60 days.

2.The exclusion of foot care is determined by the nature of the service, regardless of the clinician who performs the service.

Loss of protective sensation (LOPS) is not the subject of this LCD.

Summary of Evidence

N/A

Analysis of Evidence

N/A

Associated Information

Documentation Requirements

• All indications must be clearly documented in the patient’s medical record and made available to the A/B MAC upon request.

• Documentation supporting medical necessity, such as physical and/or clinical findings consistent with the diagnosis and indicative of severe peripheral involvement must be maintained in the patient record.

• Physical findings and services must be precise and specific (e.g., left great toe, or right foot, 4th digit.) Documentation of co-existing systemic illness should be maintained.

• There must be adequate medical documentation to demonstrate the need for routine foot care services as outlined in this LCD. This documentation may be office records, physician notes or diagnoses characterizing the patient’s physical status as being of such severity to meet the criteria for exceptions to the Medicare routine foot care exclusion.

• For each service encounter for debridement of mycotic nails, the medical record should contain a description of each debrided nail that reflects clinical descriptors consistent with mycotic nails . If appropriate the clinical descriptor may encompass multiple nails with the same findings. (e.g., the nail for toes 1, 3, 5 are yellow, brittle, thickened, etc.)

• When the documentation does not meet the criteria for the service rendered, or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.

Utilization GuidelinesRoutine foot care services are considered medically necessary once (1) in 60 days.

Bibliography

Other Medicare Contractor’s Local Coverage Determinations.