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Enhanced Podiatry Services (UAW Retiree Medicare Plus Blue PPO) - Coverage Criteria

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Defines coverage, coding, provider/payment rules, and limits for enhanced podiatry services under the UAW Retiree Medical Benefits Trust Medicare Plus Blue PPO plan and who may provide and bill for these services.

Policy Summary

Payerblue cross blue shield - michigan

PolicyEnhanced Podiatry Services (UAW Retiree Medicare Plus Blue PPO) - Coverage Criteria

Policy CodePolicy N/A

Change TypeMinor technical update / no material change

Effective DateJan 1, 2026

Next Review DateTBD

Key ActionObtain a coverage determination from Medicare Plus Blue when coverage is uncertain before providing items.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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Currentblue cross blue shield - michiganPolicy N/A

Enhanced Podiatry Services (UAW Retiree Medicare Plus Blue PPO) - Coverage Criteria

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Policy Summary

Payerblue cross blue shield - michigan

PolicyEnhanced Podiatry Services (UAW Retiree Medicare Plus Blue PPO) - Coverage Criteria

Policy CodePolicy N/A

Change TypeMinor technical update / no material change

Effective DateJan 1, 2026

Next Review DateTBD

Key ActionObtain a coverage determination from Medicare Plus Blue when coverage is uncertain before providing items.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Enhanced Podiatry Benefit — Coverage Criteria

Enhanced podiatry benefit coverage criteria

Covered when the following group-level conditions are met:

Group and plan applicability: Service is provided to members under the UAW Retiree Medical Benefits Trust Medicare Plus Blue PPO plan (an enhanced Medicare Advantage benefit) that uses Original Medicare as a base; the group determines the scope, reimbursement, maximum payment amounts, and member cost sharing for this enhanced benefit.

Visit frequency limit: Routine foot care is covered up to 6 visits per year.<= 6 visits/year

Provider eligibility: Services must be provided by eligible providers: M.D., D.O., D.P.M., Registered Nurse, Nurse Practitioner, Clinical Nurse Specialist, or Physician Assistant.

Payable locations include office, home, urgent care centers, and retail health centers.

Covered services and codes: Routine foot care (preventive treatment of the foot, removal of corns and calluses, trimming/cutting/clipping of nails, wart care) and diabetic LOPS evaluations where applicable are covered under this enhanced benefit per the listed CPT/HCPCS codes.

Covered CPT/HCPCS codes: G0245, G0246, G0247, 11055, 11056, 11057, 11719, 11720, 11721.

Payment and member cost share: Enhanced podiatry services are covered at 100% of the approved amount up to plan limits; there is no member cost sharing for enhanced podiatry services.

Providers may not balance-bill members for covered services; scope and payment methodology determined by the group.

If a member elects to receive a noncovered service, the member is responsible for the entire charge for that noncovered service. Providers may not have members sign an Advance Beneficiary Notice of Noncoverage (ABN) to accept financial responsibility for noncovered items under this plan. If there is any uncertainty about coverage, providers should obtain a coverage determination from Medicare Plus Blue before providing the service. If a provider issues a noncovered item to a member without first obtaining a coverage determination, the member must be held harmless for all charges except for any otherwise applicable cost share.

Medicare Plus Blue uses Original Medicare (Part A and Part B) as the base program but may offer enhanced benefits beyond Original Medicare within the Medicare Plus Blue PPO plan selected by the group. Because Original Medicare generally excludes routine foot care unless specific exceptions apply, this enhanced podiatry benefit clarifies the group-selected scope of coverage and payment rules. The plan provides such services at 100% of the approved amount under the group benefit and may expand or modify Medicare’s usual coverage limitations as described in this policy. When in doubt about whether a service is covered under the enhanced benefit, providers should seek a coverage determination from Medicare Plus Blue prior to providing care.

Applicable Codes and Diagnosis

Covered CPT/HCPCS Codes (routine foot care, corn removal)CPT | HCPCSCovered

G0245	Initial physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) — includes diagnosis of LOPS, history, specified physical exam elements, footwear evaluation, and education.
G0246	Follow-up physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in LOPS — includes history, specified physical exam elements, footwear evaluation, and education.
G0247	Routine foot care by a physician of a diabetic patient with LOPS — includes local care of superficial wounds, debridement of corns and calluses, trimming and debridement of nails.
11055	Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion.
11056	Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); 2 to 4 lesions.
11057	Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); more than 4 lesions.

Covered CPT Codes (nail care)CPTCovered

11719	Trimming of nondystrophic nails, any number.
11720	Debridement of nail(s) by any method(s); 1 to 5.
11721	Debridement of nail(s) by any method(s); 6 or more.

ICD-10ICD-10

ICD-10: Not Applicable

Document states 'Not Applicable' for ICD-10 codes in this policy.

Provider Billing, Authorization and Member Financial Protections

Prior Authorization

Obtain coverage determination when coverage is uncertain

If there is any question about whether an item is covered, obtain a coverage determination from Medicare Plus Blue before providing the item to the member.

Note

Confirm provider eligibility, plan applicability, and visit limits

Providers must follow eligibility and payment conditions: ensure services are furnished by eligible providers (M.D., D.O., D.P.M., RN/NP/CNS/PA), limit routine foot care to the covered visit frequency, and verify member benefits and plan applicability prior to treatment.

Verify member is enrolled in the UAW Retiree Medical Benefits Trust Medicare Plus Blue PPO plan and that the enhanced benefit applies.
Ensure the provider rendering services is one of the eligible provider types listed.
Confirm routine foot care visit limits (up to 6 visits/year) before scheduling additional visits.

Background and Clinical Context

Podiatry addresses disorders of the foot, heel, ankle and lower leg. Under Original Medicare Part B, routine foot care is generally excluded except for specific medically necessary indications (for example, related diabetic complications). This Medicare Plus Blue enhanced benefit for members of the UAW Retiree Medical Benefits Trust Medicare Plus Blue PPO plan aligns with Medicare where applicable but permits the group to define expanded coverage. Specifically, the enhanced benefit covers routine foot care services (preventive foot treatment, removal of corns and calluses, trimming and debridement of nails, wart care) and diabetic LOPS evaluations at 100% of the approved amount, limited to up to 6 visits per year.

Key Definitions

LOPS (Loss of Protective Sensation) — definition and requirements

TermLoss of Protective Sensation (LOPS)

DefinitionDiabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) as used for G0245–G0247: sensory loss that is identified during evaluation and documented in the medical record.

Required exam elementsEvaluation must include: visual inspection of forefoot, hindfoot, and toe web spaces; evaluation of protective sensation; evaluation of foot structure and biomechanics; evaluation of vascular status and skin integrity; evaluation and recommendation of footwear; and patient education.

DocumentationProvider must document the diagnosis of LOPS, patient history, the required physical exam elements listed above, footwear evaluation/recommendation, and patient education to support use of G0245–G0247.

Services linked to LOPSG0245 (initial E/M), G0246 (follow-up E/M), and G0247 (routine foot care) are specific to diabetic patients with LOPS and describe included elements such as local care of superficial wounds, debridement of corns/calluses, and nail trimming/debridement when present.