Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Surgical Treatment of Nails
Policy #:MA11.036c

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

Surgical treatment of nails is considered medically necessary and, therefore, covered for any of the following indications:
  • Complicated injury of the toes or fingers involving the nail component severe enough to require removal of the nail
  • Deformed nails that prevent wearing shoes or otherwise jeopardize the integrity of the toe
  • Ingrown toenails
  • Onychogryposis (i.e., thickening and curvature of the nails resembling claws or a ram's horn) or onychauxis (i.e., overgrowth or thickening of the nail)
  • Severe or recurrent fungal nail infection that has failed to respond to usual, less invasive treatment (e.g., pharmacological treatment, debridement)
  • Subungual abscess (i.e., a bacterial infection of the nail bed)

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

When a nail avulsion is performed, another avulsion should not be required for at least 12 weeks.

This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, surgical treatment of nails is covered under the medical benefits of the Company's Medicare Advantage products when the medical necessity criteria listed in this policy are met.

Description

An ingrown nail is a condition in which the nail edge has grown into the surrounding soft tissue, resulting in possible pain, inflammation, or infection. This condition most commonly occurs in the great toes and may require surgical management. Other conditions may also require avulsion of part or all of the nail.

Treatment of a simple uncomplicated or asymptomatic ingrowing nail by removal of the offending nail spicule, not requiring local anesthesia, is considered to routine foot care. Trimming, cutting, clipping, and debriding of a nail distal to the eponychium are also considered routine foot care.

Nail avulsions usually offer only temporary relief for ingrown toenails. The nail often grows back to its original thickness, and the offending margin may again become problematic, resulting in another nail avulsion. Therefore, a partial or complete excision of nail and nail matrix may be the preferred course of treatment for recurrent ingrown nails.

Avulsion of a nail plate is, generally, performed under local anesthesia. This procedure involves the separation and removal of a border of the nail or removal of the entire nail from the nail bed to the eponychium.

Excision of nail and nail matrix is performed under local anesthesia and requires removal of part or all of the nail along its length, with destruction or permanent removal of the matrix (e.g., chemical/surgical matrixectomy).

Wedge excision of skin of nail fold is designed to relieve pressure on the nail/soft tissue and requires an excision of a wedge of the soft tissue and ingrown nail from the involved side of the toe.
References

Novitas Solutions. Local Coverage Determination (L34887). Surgical Treatment of Nails. [Novitas Solutions Web site]. Original:10/01/2015. (Revised: 01/01/2017). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34887&ver=22&name=314*1&UpdatePeriod=672&bc=AQAAEAAAIAAAAA%3d%3d&. Accessed January 4, 2019.

Novitas Solutions. Local Coverage Article. (A52998). Surgical Treatment of Nails. [Novitas Solutions Web site]. Original: 10/01/2015. (Revised:01/01/2017). Available at:https://www.cms.gov/medicare-coverage-database/license/cpt-license.aspx?from=~/overview-and-quick-search.aspx&npage=/medicare-coverage-database/details/article-details.aspx&articleId=52998&ver=11&name=314*1&UpdatePeriod=711&bc=AQAAEAAAAAAAAA%3d%3d&. Accessed January 4, 2019.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

11730, 11732, 11750, 11765


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

Refer to Attachment A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Surgical Treatment of Nails
Description: ICD-10 Diagnosis Codes







Policy History

MA11.036c
02/12/2020This policy has been reissued in accordance with the Company's annual review process.
02/13/2019This policy has been reviewed and reissued to communicate the Company’s continuing position on the Surgical Treatment of Nails.
04/25/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on the Surgical Treatment of Nails.
04/21/2017To be consistent with Medicare the following coding changes were made.

The following ICD-10 CM codes have been added to this policy:
    T25.339A Burn of third degree of unspecified toe(s) (nail), initial encounter
    T25.339D Burn of third degree of unspecified toe(s) (nail), subsequent encounter
    T25.339S Burn of third degree of unspecified toe(s) (nail), sequela
    T25.739A Corrosion of third degree of unspecified toe(s) (nail), initial encounter
    T25.739D Corrosion of third degree of unspecified toe(s) (nail), subsequent encounter
    T25.739S Corrosion of third degree of unspecified toe(s) (nail), sequela
The following ICD-10 CM codes have been deleted from this policy:
    S61.318A Laceration without foreign body of other finger with damage to nail, initial encounter
    S61.318D Laceration without foreign body of other finger with damage to nail, subsequent encounter
    S61.318S Laceration without foreign body of other finger with damage to nail, sequela
    S61.328A Laceration with foreign body of other finger with damage to nail, initial encounter
    S61.328D Laceration with foreign body of other finger with damage to nail, subsequent encounter
    S61.328S Laceration with foreign body of other finger with damage to nail, sequela
    S61.338A Puncture wound without foreign body of other finger with damage to nail, initial encounter
    S61.338D Puncture wound without foreign body of other finger with damage to nail, subsequent encounter
    S61.338S Puncture wound without foreign body of other finger with damage to nail, sequela
    S61.348A Puncture wound with foreign body of other finger with damage to nail, initial encounter
    S61.348D Puncture wound with foreign body of other finger with damage to nail, subsequent encounter
    S61.348S Puncture wound with foreign body of other finger with damage to nail, sequela
    S61.358A Open bite of other finger with damage to nail, initial encounter
    S61.358D Open bite of other finger with damage to nail, subsequent encounter
    S61.358S Open bite of other finger with damage to nail, sequela


Revisions from MA11.036b
07/13/2016This version of the policy will become effective 07/13/2016.

Additional covered indications were added to the policy section.

Additional ICD 10 codes were added to the coding table


Revisions from MA11.036a
10/23/2015This version of the policy will become effective 10/23/2015.

Revised policy number MA11.036a was issued as a result of annual policy review.

This policy was updated to revise coverage criteria related to surgical treatment of nails.


Revisions from MA11.036
01/01/2015This is a new policy.




Version Effective Date: 04/21/2017
Version Issued Date: 04/21/2017
Version Reissued Date: 02/14/2020