Coverage Criteria and Medical Necessity with Medicare

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Mar 16th, 2016 - Reviewed/Updated Aug 3rd

In the absence of a systemic condition, treatment of mycotic nails may be covered. The treatment of mycotic nails for an ambulatory patient is covered only when the physician attending the patient's mycotic condition documents that (1) there is clinical evidence of mycosis of the toenail, and (2) the patient has marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

The treatment of mycotic nails for a non-ambulatory patient is covered only when the physician attending the patient's mycotic condition documents that (1) there is clinical evidence of mycosis of the toenail, and (2) the patient suffers from pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

The following metabolic, neurologic, and peripheral vascular diseases (with synonyms in parentheses) most commonly represent the underlying conditions that may justify coverage for routine foot care. Please note, this list is not comprehensive.

• Diabetes mellitus *
• Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis)
• Buerger's disease (thromboangiitis obliterans)
• Chronic thrombophlebitis *
• Peripheral neuropathies involving the feet

-    Associated with malnutrition and vitamin deficiency *

• Malnutrition (general, pellagra)
• Alcoholism
• Malabsorption (celiac disease, tropical sprue)
• Pernicious anemia 
  • Associated with carcinoma *
  • Associated with diabetes mellitus *
  • Associated with drugs and toxins *
  • Associated with multiple sclerosis *
  • Associated with uremia (chronic renal disease) *
  • Associated with traumatic injury
  • Associated with leprosy or neurosyphilis
  • Associated with hereditary disorders
• Hereditary sensory radicular neuropathy
• Angiokeratoma corporis diffusum (Fabry's)
• Amyloid neuropathy