CurrentCapital BlueCrossPolicy MP 2.018

Foot Care Services

This policy defines coverage and medical necessity criteria for routine and non-routine foot care services for members of Capital BlueCross products to which the policy applies.

Policy Summary

PayerCapital BlueCross

PolicyFoot Care Services

Policy CodePolicy MP 2.018

Change TypeAdministrative (coding update)

Effective Date10/1/2025

Next Review DateN/A

Key ActionConfirm member product applicability and medical necessity before billing; procedure codes are covered only when criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10/1/2025Effective date

9Procedure codes

>100Diagnosis codes listed

SelectProduct variations

5+References

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Routine Foot Care — medically necessary exceptions

Routine foot care is generally not medically necessary except when ALL of the following apply:

Routine care allowed with systemic disease: Routine foot care services may be considered medically necessary when there is systemic disease (metabolic, neurologic, or peripheral vascular) that would put the patient at risk if provided by a nonprofessional person.

Systemic diseases enumerated include diabetes mellitus, peripheral vascular disease, lymphedema (moderate to severe), peripheral neuropathies, chronic venous insufficiency, amyotrophic lateral sclerosis (ALS), arteriosclerosis obliterans, arteritis of the feet, Buerger's disease, chronic indurated cellulitis, intractable edema, Raynaud's phenomenon secondary to connective tissue disease, arterial stricture, and other conditions listed in policy.

Examples of qualifying systemic conditions: Includes but is not limited to: Amyotrophic Lateral Sclerosis (ALS); arteriosclerosis obliterans; arteritis of the feet; Buerger's disease; chronic indurated cellulitis; chronic venous insufficiency; diabetes mellitus; intractable edema; lymphedema (moderate to severe); peripheral neuropathies (associated with malnutrition, alcoholism, malabsorption, pernicious anemia, carcinoma, diabetes, drugs/toxins, multiple sclerosis, uremia/CKD, traumatic injury, leprosy or neurosyphilis, hereditary disorders, rheumatoid arthritis); peripheral vascular disease; Raynaud's phenomenon secondary to connective tissue disease; stricture of artery.

See policy text (full enumerated list) for additional associated conditions and details.

Evaluation and debridement of mycotic nails

Evaluation and debridement of mycotic nails may be considered medically necessary when either of the following are met:

Mycotic nail criteria A: Patient has a systemic condition listed in the policy (see Routine Foot Care criteria).

If a qualifying systemic condition is present, evaluation and debridement of mycotic nails may be medically necessary.

Mycotic nail criteria B: In the absence of a systemic condition, the patient is diagnosed with tinea unguium (onychomycosis) AND either has pain and/or secondary infection from nail dystrophy OR, if ambulatory, marked limitation of ambulation (pain and/or abnormality of gait).

Both the diagnosis of tinea unguium and at least one of the complication/functional criteria are required.

Any service performed in the absence of a localized foot illness, injury, or symptoms involving the foot is classified as routine foot care. Examples include clipping, trimming, or debridement of nails; shaving, paring, cutting, or removal of corns and calluses; simple palliative treatments for plantar warts that do not require cautery or curettage; general hygiene and preventive maintenance such as cleaning, soaking, or use of skin creams; and treatment of uncomplicated, asymptomatic ingrown nails that do not require local anesthesia. Such services do not typically require the skills of a qualified foot care provider unless other medical criteria are met.

Policy history entries dated 06/14/2024 and 05/07/2025 record consensus reviews with no change to the policy stance. An administrative update on 09/02/2025 notes that new ICD-10 codes were added effective 10/01/2025.

Routine foot care that does not meet the policy's systemic disease or the functional/diagnostic criteria is considered not medically necessary. While routine services are generally simple hygiene or preventive maintenance that may be done by nonprofessional caregivers, patients with qualifying systemic conditions (for example, diabetes or peripheral vascular disease) may require professionally delivered foot care to reduce risk of complications; absent those criteria, coverage is not indicated.

Procedure and Diagnosis Codes

Covered procedure codesCPTCovered

11055	Procedure code listed as covered when medically necessary
11056	Procedure code listed as covered when medically necessary
11057	Procedure code listed as covered when medically necessary
11719	Procedure code listed as covered when medically necessary
11720	Procedure code listed as covered when medically necessary
11721	Procedure code listed as covered when medically necessary
G0127	Procedure code listed as covered when medically necessary
G0247	Procedure code listed as covered when medically necessary
S0390	Procedure code listed as covered when medically necessary

Examples of covered ICD-10 diagnosis codes (partial list)ICD-10

A30.0	Indeterminate leprosy
B35.1	Tinea unguium
D51.0	Vitamin B12 deficiency anemia due to intrinsic factor deficiency
E08.621	Diabetes mellitus due to underlying condition with foot ulcer
E10.621	Type 1 diabetes mellitus with foot ulcer
E11.621	Type 2 diabetes mellitus with foot ulcer

Diabetes-related ICD-10 codes (selection)ICD-10

E11.44	Type 2 diabetes mellitus with diabetic amyotrophy
E11.49	Type 2 diabetes mellitus with other diabetic neurological complication
E11.51	Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene
E11.52	Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E11.59	Type 2 diabetes mellitus with other circulatory complications
E11.610	Type 2 diabetes mellitus with diabetic neuropathic arthropathy
E11.618	Type 2 diabetes mellitus with other diabetic arthropathy
E11.620	Type 2 diabetes mellitus with diabetic dermatitis
E11.621	Type 2 diabetes mellitus with foot ulcer
E11.622	Type 2 diabetes mellitus with other skin ulcer

1–10 of 17

1/2

Neuropathy and peripheral nervous system codes (selection)ICD-10

G60.0	Hereditary motor and sensory neuropathy
G60.3	Idiopathic progressive neuropathy
G61.0	Guillain-Barre syndrome
G61.81	Chronic inflammatory demyelinating polyneuritis
G62.0	Drug-induced polyneuropathy
G62.1	Alcoholic polyneuropathy
G63	Polyneuropathy in diseases classified elsewhere
G90.09	Other idiopathic peripheral autonomic neuropathy

Peripheral vascular and venous disorder codes (selection)ICD-10

I70.201	Unspecified atherosclerosis of native arteries of extremities, right leg
I70.211	Atherosclerosis of native arteries of extremities with intermittent claudication, right leg
I70.221	Atherosclerosis of native arteries of extremities with rest pain, right leg
I70.231	Atherosclerosis of native arteries of right leg with ulceration of thigh
I70.261	Atherosclerosis of native arteries of extremities with gangrene, right leg
I73.00	Raynaud's syndrome without gangrene
I73.1	Thromboangiitis obliterans [Buerger's disease]
I87.2	Venous insufficiency (chronic) (peripheral)
I87.311	Chronic venous hypertension (idiopathic) with ulcer of right lower extremity

Infection and skin condition codes (selection)ICD-10

L02.611	Cutaneous abscess of right foot
L03.031	Cellulitis of right toe
L03.115	Cellulitis of right lower limb
L03.41	Acute lymphangitis of right toe
L98.3	Eosinophilic cellulitis [Wells]

Renal, history, and edema codes (selection)ICD-10

N18.30	Chronic kidney disease, stage 3 unspecified
N18.31	Chronic kidney disease, stage 3a
N18.32	Chronic kidney disease, stage 3b
N18.4	Chronic kidney disease, stage 4 (severe)
N18.5	Chronic kidney disease, stage 5
N18.6	End stage renal disease
Z86.31	Personal history of diabetic foot ulcer
R60.0	Localized edema

Provider Requirements and Administrative Notes

Prior Authorization

Prior Authorization and Product-Specific Applicability

Prior authorization and product-specific applicability may vary by product. Some products administered by Capital Blue Cross may refer to alternate policies or have different requirements; verify the member's specific product and benefits before providing services.

This policy applies only to certain Capital Blue Cross programs and products; benefit variations are discussed elsewhere in the policy.
FEP PPO: Refer to the FEP Medical Policy Manual for FEP-specific guidance.

Prior Authorization

No specific prior authorization requirements are detailed in this policy text. Providers should confirm prior authorization requirements through the member’s benefit plan or the payer’s provider portal, as some products or services may require authorization even when not specified here.

Note

Provider Action

None specified in this part of the document. There are no additional provider actions listed in this section beyond verifying product applicability and prior authorization as noted above.

Billing Rule

Code-List Caveat

Coding caveat: The list of codes in the Coding Information section may not be all-inclusive. The identification of a code does not indicate coverage; coverage is determined by the member’s benefit information. Codes are subject to change at any time and not all covered services are eligible for separate reimbursement.

Verify code applicability and coverage with current member benefits before billing.
Coding lists are illustrative and not exhaustive.

Key Definitions

MYCOTIC

TermMYCOTIC

DefinitionCaused by or infected with fungus.

ContextUsed in policy to describe fungal involvement of nails or skin relevant to coverage for evaluation and debridement.

NON-ROUTINE FOOT CARE

TermNON-ROUTINE FOOT CARE

DefinitionIncludes surgical treatment of structural defects or anomalies (e.g., fractures, hammer toes, bunions) and surgery for ingrown toenails; injectable local anesthetic must be used for a procedure to be considered toenail surgery.

ContextDistinguished from routine maintenance services and generally requires professional surgical intervention.

KERATOMA (callus)

TermKERATOMA (callus)

DefinitionHard, light-colored patches of skin that develop as a result of friction or pressure.

ContextListed among foot conditions addressed by podiatric care; may be treated nonsurgically as part of routine or non-routine services depending on clinical circumstances.

TYLOMA

TermTYLOMA

DefinitionA localized overgrowth of skin due to pressure or friction.

ContextMay be clinically relevant when assessing causes of localized skin breakdown or pain on the foot.

ROUTINE FOOT CARE

TermROUTINE FOOT CARE

DefinitionHygiene and maintenance care such as cleaning and soaking of feet, use of skin creams, trimming nails (except surgery for ingrown nails), treatment of corns, calluses, keratoses, nonsurgical bunion treatment, and treatment/debridement of mycotic nails.

Coverage NoteGenerally not medically necessary unless the patient meets the policy's systemic disease or functional/diagnostic criteria.

Diabetic peripheral neuropathy / loss of protective sensation

TopicDiabetic peripheral neuropathy / loss of protective sensation

Reference GuidanceReferenced via CMS NCD 70.2.1 (Services for Diagnosis and Treatment of Diabetic Sensory Neuropathy with Loss of Protective Sensation) and clinical guidance from the ADA and IWGDF.

ContextCited as a relevant condition in policy for determining when routine foot care may be medically necessary for patients at increased risk.

Policy History and Revisions

2025-09-02administrative_updateLatest

Administrative update adding new ICD codes effective 10/01/2025.

2025-05-07consensus_review

Consensus review — no change to policy stance; added ICD‑10 codes E10.A0–E10.A2.

2024-06-14consensus_review

Consensus review — no change to policy stance; new references added.

2023-05-30consensus_review

Consensus review — references updated, coding reviewed; deleted ICD‑10 codes S99.821A and S99.822A and added E11.10 and E11.649.

2022-09-21consensus_review

Consensus review — coding reviewed and ICD‑10 codes updated (added A30.9, A52.19, E09.8, I87.329, I87.339, I87.399, N18.30, N18.31, N18.32); references updated.

OpenPayer

Foot Care Services

Coverage and Medical Necessity Criteria

Procedure and Diagnosis Codes

Provider Requirements and Administrative Notes

Key Definitions

Background and Scope

Policy History and Revisions