FOOT CARE (Foot care services coverage criteria)
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Governs coverage of foot-care services (corrective surgery, structural deformity treatment, traumatic injury management, nail and skin procedures) for Priority Health members when clinical criteria, documentation, and conservative management requirements are met.
No material clinical or coverage changes in this revision.
Coverage Criteria for Foot Care Services
Bunionectomy
Covered when ALL of the following are met:
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Cheilectomy
Covered when ALL of the following are met:
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Injections and aspirations of joints
Covered with limits:
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Mycotic toenail treatment / Nail debridement
Covered when specific conditions are met:
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Hammer toe surgical intervention
Covered when ALL of the following are met:
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Fracture care billing rules
Covered fracture care services and billing notes:
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Podiatric office surgery
Covered with bundling rules:
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Medical necessity and investigational exceptions
Coverage determinations and exceptions
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The policy excludes several specific treatments from routine coverage. Acupuncture is not covered except when the member’s benefit plan includes a rider that specifically allows acupuncture. Extracorporeal shock wave therapy (ESWT) for plantar fasciitis is referenced as non-covered here and is addressed separately in Priority Health medical policy #91527. The policy also excludes nerve blocks intended solely to increase blood supply to the foot and toes, as well as prolotherapy, joint sclerotherapy, and ligamentous injection with sclerosing agents. Routine foot care items (e.g., nail trimming, treatment of corns/calluses, basic hygienic care) are not covered except when specific systemic conditions justify an exception. Providers should refer to the coding and prior authorization sections when a question arises about whether a particular service is separately billable or requires prior approval.
Treatment of subluxation of the foot performed solely to correct the subluxated structure as an isolated entity is excluded from coverage. This exclusion does not apply to medical or surgical treatment of subluxation of the ankle (talo‑crural) joint, and acute dislocations of the foot remain covered when medically indicated.
Experimental, investigational, or unproven treatments are generally excluded from coverage. Coverage determinations for these therapies require prior plan approval only through an individual case review, and unless approved via that process they are not considered medically necessary under this policy.
An exception pathway exists for investigational or unproven therapies through individual case review. Requests for such consideration must receive prior plan approval and will be evaluated by a Priority Health medical director or clinical pharmacist. Exceptions may be considered when the member has a terminal illness or a chronic, life‑threatening, severely disabling disease causing serious clinical deterioration.
Tenotomy performed for asymptomatic or passively correctable claw toes is considered not medically necessary. Tenotomy is only covered when the claw toes are symptomatic or cannot be passively corrected; described coverage rules address when tenotomy is included with other procedures or when separate incision criteria apply.
Reinforcing the policy stance, experimental, investigational, or unproven treatments remain excluded unless coverage is granted following prior plan approval via individual case review. Providers must submit an individualized request and supporting documentation for review; final coverage determinations will be made by a Priority Health medical director or clinical pharmacist.
Billing Codes and Code Support
| see Billing Policy No. 113 | Reference to Priority Health Billing Policy No. 113 for detailed billing/CPT guidance |
| E08.00 - E13.9 | Diabetes mellitus |
| B35.1 | Tinea unguium |
| A30.0 - A30.9 | Leprosy (examples of ICD-10 codes that may support medical necessity) |
| A30.0-A30.9 | Leprosy |
| A48.0 | Gas gangrene |
| A52.10-A52.3 | Neurosyphilis |
| A69.20-A69.29 | Lyme disease |
| A80.0-A80.39 | Paralytic poliomyelitis |
| A92.30-A92.39 | West Nile virus |
| B02.23 | Postherpetic polyneuropathy |
| B20 | Human immunodeficiency virus [HIV] disease |
| B35.1 | Tinea unguium |
| B47.9 | Mycetoma, unspecified |
| 11055 | Paring or cutting of benign hyperkeratotic lesion (corn or callus); single lesion |
| 11056 | Paring or cutting of benign hyperkeratotic lesion (corn or callus); two to four lesions |
| 11057 | Paring or cutting of benign hyperkeratotic lesion (corn or callus); more than four lesions |
| 11719 | Trimming of non-dystrophic nails, any number |
| G0127 | Trimming of 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 |
| 11730 | Avulsion of nail plate, partial or complete, simple; single |
| 11732 | Avulsion of nail plate, partial or complete, simple; each additional nail plate |
| 20600 | Arthrocentesis, aspiration and/or injection, small joint or bursa; without ultrasound guidance |
| 28010 | Tenotomy, percutaneous, toe; single tendon |
| 28011 | Tenotomy, percutaneous, toe; multiple tendons |
| 28055 | Neurectomy, intrinsic musculature of foot |
| 28080 | Excision, interdigital (Morton) neuroma, single, each |
| 28104 | Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or calcaneus |
| 28106 | Excision or curettage... with iliac or other autograft (includes obtaining graft) |
| 28107 | Excision or curettage... with allograft |
Provider Responsibilities, Prior Authorization, and Documentation
Billing & prior authorization reference
Refer to Priority Health Billing Policy No. 113 for detailed billing and prior authorization guidance related to foot care and onychomycosis.
Prior authorization may be required
Prior authorization may be required for certain drugs, devices, services, and procedures; when required, providers must submit medical necessity justification with the request.
Prior authorization requirement for individual case review
Providers must obtain plan approval for individual case reviews of investigational or unproven treatments and submit prior authorization when indicated for drugs, devices, services, or procedures.
Conservative therapy expected prior to surgery
When applicable, conservative non-surgical treatments are expected prior to some surgical interventions; signs/symptoms must be unresponsive to at least 6 months of conservative care where specified.
- Examples of conservative care: padding, oral analgesics/anti-inflammatory medications, shoe modifications, splinting, orthotics, debridement, and injections where specified.
- Minimum conservative treatment duration cited for several procedures is 6 months (or 4 weeks for ulceration responding to local wound care in specified situations).
Document diagnosis and clinical findings
Document confirmed diagnoses and relevant clinical findings prior to procedural care.
- Examples: confirmed diagnosis of hallux valgus, hammertoe, or hallux rigidus and associated findings (difficulty walking, persistent pain, ulceration).
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Required clinical documentation
Providers should document confirmed diagnoses, objective measurements where required (e.g., IM angle >12°, hallux valgus angle >15°), failed conservative therapy durations and measures, and indications for surgery or procedures.
- Include objective measurements when applicable: intermetatarsal (IM) angle >12° and hallux valgus angle >15°.
- Document duration and specifics of conservative therapy (e.g., at least 6 months including padding, medications, shoe modifications).
Prior authorization documentation required
When prior authorization is required, providers must submit a request demonstrating that the drug, device, service, or procedure is medically necessary; include supporting clinical documentation.
- Follow Priority Health Provider Manual guidance for submission requirements.
Documentation required for prior authorization
Providers must include documentation demonstrating medical necessity when prior authorization is required, such as applicable diagnosis codes and clinical rationale.
- For Medicaid members, include the appropriate Michigan Medicaid Fee Schedule codes as applicable.
Document conservative care and symptoms (evidence required)
Document trials of conservative management (e.g., at least 6 months of padding, oral analgesics/anti-inflammatories, shoe modifications or orthotics/splinting where specified) and evidence of functional limitation (difficulty walking, significant persistent pain, ulceration) to support medical necessity.
- Failure to document these trials may trigger denial of coverage for surgical procedures such as bunionectomy, cheilectomy, or hammer toe surgery.
Denial risk for experimental or investigational treatments
Coverage determinations for experimental, investigational, or unproven treatments may be denied unless individual case review and prior plan approval are obtained; exceptions may be considered for terminal illness or chronic, life‑threatening, severely disabling disease.
- All determinations for experimental/investigational treatments are made by a Priority Health medical director or clinical pharmacist.
Clinical Background
Hallux rigidus is a degenerative arthritic condition of the first metatarsophalangeal (MTP) joint. Injection therapy, including intra‑articular corticosteroids or hyaluronic acid, has mixed and limited evidence for durable benefit; many patients who receive injections ultimately proceed to surgical intervention within one to two years. The literature and policy commentary do not support consistent long‑term efficacy for injections, and other regenerative approaches such as prolotherapy lack sufficient evidence to establish benefit. Given this limited and heterogeneous evidence base, intra‑articular injections are covered only within the injection frequency limits described elsewhere in the policy and may be subject to prior authorization and documentation of failed conservative care.
Definitions and Key Terms
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