Foot care services include the examination, diagnosis, and medical or surgical treatment of conditions and dysfunctions of the foot.

Foot care services are considered medically necessary when all of the following criteria are met:

• the services are delivered by a qualified provider of foot care services. A qualified provider is one who is licensed and is performing within the scope of licensure; and
• the services are considered by the Plan to be specific, effective, and reasonable treatment for the patient’s diagnosis and condition.

Routine foot care, i.e., hygiene and preventive maintenance such as trimming of corns, calluses, or nails, does not usually require the skills of a qualified provider of foot care services, and, as such is considered not medically necessary. However, for patients with comorbidities such, as diabetes or peripheral vascular disease, which can impede healing and can jeopardize life or limb, routine foot care is considered medically necessary.

Manual debridement and electric grinding procedures of the toenails, when performed by qualified providers, are considered medically necessary only for the following conditions:

• onychomycosis (mycotic nails), when confirmed by positive culture or by documented signs and symptoms, which substantiate difficulty in wearing shoes or in ambulation;
• onychauxis (club nail), onychodystrophy (deformed nail), and onychogryposis (thickened nail), when such conditions result in paronychia or pain from gross distortions of the nail, as well as difficulty in wearing shoes or in ambulation.

Pre-operative, non-invasive vascular studies (Doppler or segmental plethysmography or duplex scan) are considered medically necessary with the following diagnoses, symptoms, or signs:

• Symptomatic peripheral arterial disease, e.g., arteriosclerosis obliterans, Buerger’s disease; diabetes mellitus;
• Non-traumatic amputation of the foot or any part thereof;
• Ischemic ulcer;
• Intermittent claudication or other ischemic-type pain; OR
• At least three (3) of the following:
  1. non-palpable pedal pulses;
  2. decreased hair growth in the leg;
  3. nail overgrowth;
  4. abnormal skin texture (thinning);
  5. abnormal skin color/temperature (i.e., cold feet);
  6. pigmentation changes.

Nerve blocks performed for the purpose of increasing blood supply to the foot and toes are considered not medically necessary.

At a minimum, an injectable local anesthetic must be used in order for a foot care procedure to be considered “toenail surgery.”

Preoperative x-rays are medically necessary when performing:

• invasive procedures, including closed or open reduction internal fixations, on bones or soft tissue of the foot; or
• closed reduction of fracture(s), fracture/dislocation, or dislocation of the foot;
• ruling out of foreign body in the foot.

Bilateral x-rays of the feet are medically necessary for:

• bilateral conditions/diagnoses that require bilateral procedures;
• pediatric foot conditions prior to closure of growth plates; foot conditions/or
• congenital conditions such as tarsal coalition, accessory navicular, and bipartite sesamoids.

Postoperative x-rays of the foot are medically necessary when performing:

• invasive procedures of bones, joints, and/or soft tissue releases that can alter anatomical alignment of the foot, such as surgery for club feet;
• hardware insertion during closed or open procedures;
• after closed and/or open reduction of fractures, fracture/dislocation, and dislocation;
• only the operative side requires postoperative x-rays, even if bilateral pre-operative x-rays were performed; or
• if a radiopaque foreign body has been located and removed.

Contraindications to steroid injections are the development of avascular necrosis, infection, delayed or non-union of fractures, Charcot joints, and neuropathy.

With the exception of osteotomies or delayed or non-union of bones, benefits for postoperative films should be limited to one and only when covered bone surgery has been performed.

Radiology services other than those listed in the guidelines are not considered medically necessary without supporting documentation.

BlueCard/National Account Issues

Services that are generally considered to be routine foot care services are considered to be medically necessary if incidental to a medically necessary, skilled procedure (e.g., toenail trimming prior to application of a restrictive cast). In most cases, such services are considered to be part of the global surgical fee, and no additional benefits are provided, unless performed of necessity by a different provider.

When partial or total removal of a toenail by surgical means is performed for distorted nails or infections such as onychomycosis, onychauxis, onychogryposis or onychocryptosis (ingrown toenail), removal of medial and lateral (tibial and fibular) borders is considered to be an integral part of the procedure, and no additional benefits are provided.

Benefits are provided for only the primary procedure when a procedure is composed of several components that are considered to be part of the primary procedure, e.g., bunionectomy with sesamoidectomy, tendon surgery, and surgery for hammertoe.

Doppler studies or segmental arterial pressure measurements using a stethoscope or hand-held Doppler ultrasound are considered to be part of the office visit, and no additional benefits should be provided.

All non-invasive vascular studies imply bilateral examination; bilateral comparison studies are therefore provided as a single unit. Benefits are provided at a lesser fee for unilateral examination.

Laboratory procedures relating to foot care must be medically necessary for the condition that is being treated and must be performed by a qualified provider of laboratory services.

Nerve blocks, including somatic nerve blocks, performed for local anesthesia purposes are considered an integral part of the procedure, and no additional benefits are provided.

Medication used with arthrocentesis is included in the basic allowance for the procedure, and no additional benefits are provided.

The research for this policy was complied using a combination of standard billing practices, local Plan policies, and claims experience.

Chiropody
Foot care services
Orthopedic surgery
Orthotics
Podiatric medicine