CurrentAetnaPolicy 0046

Routine Foot Care

Defines Aetna's coverage stance on routine foot care, listing when routine foot care and debridement of mycotic nails are considered medically necessary and providing applicable CPT/HCPCS/ICD-10 codes and exclusions.

Policy Summary

PayerAetna

PolicyRoutine Foot Care

Policy CodePolicy 0046

Change TypeNo material changes

Effective DateAug 7, 1995

Next Review DateJan 11, 2024

Key ActionProviders must document underlying systemic conditions, focal infection, pain, limitation of ambulation, or that the procedure is integral to an otherwise covered service to justify coverage of routine foot care services.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

CoverageRoutine foot care generally not covered; exceptions listed

CodesMultiple CPT/HCPCS/ICD-10 codes enumerated

2023-03-06Last reviewed

Coverage Summary

Defines Aetna's coverage stance on routine foot care: routine foot care is not covered under most Aetna plans unless exception circumstances are met. Exceptions include when the service would be hazardous if performed by a non-professional because of an underlying condition, when the foot care is a necessary and integral part of an otherwise covered service, or when debridement of mycotic nails is required because the mycosis/dystrophy causes secondary infection and/or pain leading to marked limitation of ambulation and requiring professional skills. Effective date: 1995-08-07. Last review: 2023-03-06. Next review: 2024-01-11.

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Medical-Necessity Criteria

Medical Necessity — General Routine Foot Care

Routine foot care is considered non-covered under most plans unless ALL of the following exception circumstances apply:

Covered only when one or more of the following exceptions apply

The non-professional performance of the service would be hazardous for the member because of an underlying condition or disease
Routine foot care is performed as a necessary and integral part of an otherwise covered service (e.g., debriding of a nail to expose a subungual ulcer, or treatment of warts)
Debridement of mycotic nails is undertaken when the mycosis/dystrophy of the toenail is causing secondary infection and/or pain resulting or likely to result in marked limitation of ambulation and requiring the professional skills of a provider

Definitions of Routine Foot Care Services

Routine foot care includes, but is not limited to, the following services which are generally not covered unless exception criteria are met:

ALL of the following

Treatment of bunions (except capsular or bone surgery thereof), calluses, clavus, corns, hyperkeratosis and keratotic lesions, keratoderma, nails (except surgery for ingrown nails), plantar keratosis, tyloma or tylomata, and tylosis
Reduction of nails, including the trimming of nails
Pedicure services and routine cutting of nails in the absence of disease of nails are not considered treatment of disease

Debridement of Mycotic Nails — Coverage Criteria

Debridement of mycotic nails is covered when ALL of the following are met:

ALL of the following

Mycosis/dystrophy of the toenail is present (e.g., onychomycosis)
Mycosis/dystrophy is causing secondary infection and/or pain
Condition results or would result in marked limitation of ambulation
Procedure requires the professional skills of a provider

Examples of Underlying Conditions That May Justify Coverage

Routine foot care may be covered for individuals with systemic conditions that make non-professional performance hazardous. ONE or more of these conditions may justify coverage:

ANY of the following

Arteriosclerosis
Chronic thrombophlebitis
Diabetes mellitus
Peripheral neuropathies

Coding

Routine foot care CPT codes (generally not covered unless criteria met)CPTNot Covered

11055	Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion
11056	Paring or cutting of benign hyperkeratotic lesion; two to four lesions
11057	Paring or cutting of benign hyperkeratotic lesion; more than four lesions
11730	Avulsion of nail plate, partial or complete, simple; single
11732	Each additional nail plate (list separately in addition to code for primary procedure)
11750	Excision of nail and nail matrix, partial or complete (e.g., ingrown or deformed nail) for permanent removal
11765	Wedge excision of skin of nail fold (e.g., for ingrown toenail)
17110	Destruction of benign lesion(s) (eg, warts)
17111	Destruction of benign lesion(s) (eg, warts)

Debridement of mycotic nails CPT codes (covered if selection criteria are met)CPTCovered

11719	Trimming of non-dystrophic nails, any number
11720	Debridement of nail(s) by any method(s); one to five
11721	Debridement of nail(s) by any method(s); six or more

HCPCS codes covered if selection criteria are metHCPCSCovered

G0245	Initial physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in loss of protective sensation (LOPS) including specified elements
G0246	Follow up physician evaluation and management of a diabetic patient with LOPS including specified elements
G0247	Routine foot care by a physician of a diabetic patient with LOPS to include local care of superficial wounds and debridement of corns/calluses and nails if present
S0390	Routine foot care; removal and/or trimming of corns, calluses and/or nails and preventive maintenance in specific conditions (e.g., diabetes), per visit
G0127	Trimming of dystrophic nails, any number

ICD-10 codes acceptable when selection criteria are met (non-routine coverage)ICD-10Covered

E08.00 - E13.9	Diabetes mellitus (range of diabetes codes listed in policy)
G57.00 - G57.93	Mononeuropathies of lower limb
G60.0 - G60.9	Hereditary and idiopathic neuropathy
G61.0 - G62.9	Inflammatory, other and unspecified polyneuropathy
G90.01 - G90.09	Idiopathic peripheral autonomic neuropathy
G99.0	Autonomic neuropathy in diseases classified elsewhere
I70.201 - I70.92	Atherosclerosis of native arteries and bypass graft of extremities
I73.00 - I73.9	Other peripheral vascular diseases
I77.1	Stricture of artery
I79.1	Aortitis in diseases classified elsewhere

1–10 of 28

1/3

ICD-10 codes not covered for routine indications (examples provided)ICD-10Not Covered

L84	Corns and callosities [clavus, tyloma, tylomata, and tylosis]
L85.1	Acquired keratosis [keratoderma] palmaris et plantaris [hyperkeratotic lesions, acquired keratoderma, and plantar keratosis]
M20.10 - M20.12	Hallux valgus (acquired), unspecified foot [covered for capsular or bone surgery only]
M21.611 - M21.629	Bunion

Provider Actions

Documentation Required

Document medical necessity for exceptions

Providers must document underlying systemic conditions, focal infection, pain, limitation of ambulation, or that the procedure is integral to an otherwise covered service to justify coverage of routine foot care services.

Underlying systemic condition or disease (e.g., diabetes, arteriosclerosis, peripheral neuropathy)
Presence of focal infection (e.g., abscess, cellulitis, subungual ulcer)
Documented pain related to the foot condition
Evidence of marked limitation of ambulation
Statement that procedure is integral to an otherwise covered service (e.g., debriding nail to expose a subungual ulcer, treatment of warts)

Billing Rule

Use appropriate CPT/HCPCS and ICD-10 codes when criteria met

Report the CPT/HCPCS codes listed in the policy only when selection/medical necessity criteria are met and support with corresponding ICD-10 diagnosis codes from the covered list.

Report the listed CPT and HCPCS codes only when the policy selection/medical necessity criteria are satisfied
Support the procedure code with an appropriate ICD-10 diagnosis from the policy's covered list (e.g., diabetes, peripheral neuropathy, atherosclerosis, cellulitis/abscess codes)
Use debridement-specific CPTs (11719, 11720, 11721) and HCPCS (G0127) only when debridement criteria are met

Background

Background: Aetna's policy aligns with Medicare in generally not covering routine foot care, based on the assumption that patients or their caregivers will perform hygiene and self-care. Routine foot care is considered non-covered when performed in the absence of localized illness, injury, or symptoms. Exceptions are recognized for systemic conditions (for example, metabolic, neurologic, or peripheral vascular disease, including arteriosclerosis, chronic thrombophlebitis, diabetes, and peripheral neuropathies) that produce severe circulatory deficits or areas of decreased sensation, where non-professional performance of foot care may be hazardous. Additionally, routine foot care may be covered when it is integral to an otherwise covered service (e.g., debriding a nail to expose a subungual ulcer) or when debridement of mycotic nails meets specified criteria (secondary infection and/or pain resulting or likely to result in marked limitation of ambulation and requiring professional skills).

OpenPayer