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Surgical Treatment of Nails
MA11.036d

Policy

MEDICALLY NECESSARY


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 or to release a subungual hematoma after a failed puncture aspiration
  • Deformed nails that prevent wearing shoes or otherwise jeopardize the integrity of the toe
  • Ingrown toenails or fingernails
  • Onychogryphosis (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) or hematoma
  • Subungual and periungual tumors​​
  • ​ Suspected lichen planus or psoriasis of the fingernail or toenail
  • Congenital or acquired nail dystrophies that jeopardize the integrity of the finger or toe

 


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.

BILLING REQUIREMENTS

Claims submitted for billing will need to be reported using appropriate coding representing the most specific condition and laterality.



Guidelines

When a complete nail avulsion is performed, a repeat nail avulsion on the same toe or finger should not be required more frequently than every eight months (32 weeks) for toenails or four months (16 weeks) for fingernails.

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: 01/30/2022). Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=34887&ver=44&keyword=L34887&keywordType=starts&areaId=all&docType=NCA,CAL,NCD,MEDCAC,TA,MCD,6,3,5,1,F,P&contractOption=all&sortBy=relevance&bc=1.Accessed February 2, 2022.

Novitas Solutions. Local Coverage Article. (A52998). Surgical Treatment of Nails. [Novitas Solutions Web site]. Original: 10/01/2015. (Revised: 01/30/2022). Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=52998&ver=27&keyword=L34887&keywordType=starts&areaId=all&docType=NCA,CAL,NCD,MEDCAC,TA,MCD,6,3,5,1,F,P&contractOption=all&sortBy=relevance&bc=1. Accessed February 2, 2002. ​



Coding

CPT Procedure Code Number(s)
11730, 11732, 11750, 11765

ICD - 10 Procedure Code Number(s)
N/A

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


Policy History

7/25/2022
7/25/2022
MA11.036
Medical Policy Bulletin
Medicare Advantage
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No