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    v1.0.28
    OpenPayerPolicy UpdatesPodiatryWest Virginia BMS Podiatry Coverage & Prior Auth |…
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    CurrentWest Virginia Bureau for Medical Services (Department of Human Services)Policy 519.13.1

    Podiatry (Foot and Ankle) Services Coverage Criteria

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    Defines West Virginia Medicaid coverage, prior authorization, and exclusions for podiatric services (examination, diagnosis, treatment, prevention, and care of the foot and ankle) provided by licensed podiatrists eligible to participate in WV Medicaid.

    Policy Summary
    PayerWest Virginia Bureau for Medical Services (Department of Human Services)
    PolicyPodiatry (Foot and Ankle) Services Coverage Criteria
    Policy CodePolicy Policy 519.13.1
    Change TypeNo material changes
    Effective DateJan 1, 2022
    Last ReviewJan 1, 2022
    Next Review Date
    Key ActionSubmit all requests for services requiring prior authorization via the BMS utilization management contractor's web-based portal.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    519.13.1Covered Services
    519.13.1.1Foot Care
    519.13.2Prior Auth
    519.13.3Non-Covered

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Coverage Criteria for Podiatric Services

    Covered Services and Surgical Criteria

    Covered when ALL of the following are met (for general podiatry services):

    General coverage: Service is for examination, diagnosis, treatment, prevention, or care of the foot/ankle provided by a podiatrist licensed and eligible for WV Medicaid

    See exclusions for non-covered items

    Examples of covered conditions: Treatment services for acute conditions such as infections, inflammations, and ulcers; surgeries for bunions, exostoses, hammertoes, neuromas, and ingrown toenails; reduction of fractures and dislocations of the foot and ankle; treatment of symptomatic partial displacement (e.g., osteoarthritis, bursitis, bunions, tendonitis); sprains and strains; plantar warts; debridement of mycotic nails with laboratory culture evidence and marked limitation in ambulation; orthotics and related services as specified
    Surgical correction of subluxated foot structure: Surgical correction is covered only if ALL of the following are met:ALL three required
    Subluxation criterion 1: It is an integral part of the treatment of a foot injury
    Subluxation criterion 2: It is performed to improve function of the foot
    Subluxation criterion 3: It alleviates an induced or associated symptomatic condition
    Orthotics documentation: For custom fabricated orthoses, documentation must support medical necessity of a custom device rather than a prefabricated orthosis and be available to BMS upon request

    Includes reimbursement and billing rules for orthoses and related visits

    Medically necessary ancillary services: Medically necessary laboratory and radiology services applicable to foot and ankle care and within the scope of podiatry state licensure are covered

    Non-invasive peripheral vascular studies for pre-operative diabetic patients are included

    Foot Care Coverage Criteria

    Foot care (routine procedures like corn/callus removal and nail trimming) is covered when ALL of the following are met:

    Diagnosis requirement: Member has one of the following diagnoses documented: Diabetes; Chronic thrombophlebitis; Peripheral neuropathies; Arteriosclerosis of the extremities; or Thromboangitis obliterans

    Unskilled care would place the member at increased risk of infection or greater harm

    Severity requirement: Documented clinical findings establish severity per Class A/B/C definitions and support need for foot care; apply appropriate modifier (Q7, Q8, Q9) when billing

    Class A = non-traumatic amputation; Class B = any two of absent posterior tibial pulse, advanced trophic changes (three required), or absent dorsalis pedis pulse; Class C = combination rules (one from Class B plus two from Class C or one preceding finding and two of: claudication, temperature changes, edema, abnormal spontaneous sensations, burning)

    Modifier coding: Use Q7 for one Class A finding; Q8 for two Class B findings; Q9 for one Class B and two Class C findings

    The following services and situations are specifically identified as non-covered under West Virginia Medicaid for podiatry: treatment and supportive devices for flat foot conditions regardless of underlying pathology; treatment of subluxations of the foot when performed solely to correct a subluxated structure as an isolated entity; and routine foot care performed in the absence of localized illness, injury, or symptoms. These non-covered items also include therapeutic shoes, inserts, or modifications provided to members who do not meet the policy’s coverage criteria, consultations solely to dispense or fit shoes, and deluxe or convenience features.

    Services/items not covered further include missed or failed appointments, time spent preparing reports, copies of medical reports when DHHR already paid for the original, experimental services or drugs, research/study projects, services that are not the least costly option meeting the patient’s needs, services outside a provider’s licensed scope, treatment in a podiatrist’s office when the patient can self-care at home, and conscious/local/regional/IV sedation (these anesthesia services are considered included in the procedure charge). Non-covered services are not eligible for DHHR Fair Hearing or Desk/Document review.

    Services that are denied by a primary payer as "not medically necessary" or "deemed not medically necessary" are listed as non-covered under this policy and are not eligible for West Virginia Medicaid reimbursement; such denials are also not eligible for a DHHR Fair Hearing or Desk/Document review.

    Coding, Modifiers, and Classification

    Orthotics and related coding notemixed
    No codes listed
    Foot care modifier codes for severity findingsModifier
    Q7One Class A finding
    Q8Two Class B findings
    Q9One Class B and two Class C findings
    Class A/B/C severity classification
    Class AA finding of non‑traumatic amputation of the foot or integral skeletal portion.
    Class BAny two of the following findings: absent posterior tibial pulse; advanced trophic changes (three of: decreased hair growth, nail thickening, discoloration, thin or shiny texture, reddening of skin color); absent dorsalis pedis pulse.
    Class CDefined by combination rules referenced in the policy for coding of severity (used with Class A/B findings per policy guidance).

    Provider Actions, Prior Authorization & Documentation

    Prior Authorization

    Submit prior authorization via UMC web portal

    All requests for covered services that require prior authorization must be submitted to the BMS utilization management contractor (UMC) using the UMC web‑based portal; nationally accredited, evidence‑based criteria (for example, InterQual) are used for medical necessity review.

    • Access the UMC web-based portal to initiate prior authorization requests.
    • Use the UMC for medical necessity determinations; BMS‑approved appropriateness criteria (e.g., InterQual) will be applied.
    Note

    Ensure referral and severity findings are documented

    Ensure the written referral requirement for foot care is present in the medical record when applicable, and provide clinical findings that establish required severity classifications for covered foot care.

    • A written referral from an enrolled practitioner who treated the member within the past six months must be in the medical record for foot care.

    Definitions

    Custom Orthopedic Shoes
    DefinitionShoes that are custom molded and manufactured according to the member's specifications and prescribed by a practitioner, doctor of osteopathy, nurse practitioner, or podiatrist.
    PrescriberMust be prescribed by an authorized practitioner (practitioner, doctor of osteopathy, nurse practitioner, or podiatrist).
    CustomizationConstructed and molded to the member's individual specifications (not off‑the‑shelf).
    Routine Foot Care
    DefinitionAny service performed involving the foot in the absence of localized illness, injury, or symptoms.
    ExamplesCutting or removal of corns, calluses, or warts (excluding plantar warts); trimming of nails, including mycotic nails; cleaning and soaking of feet; applications of topical medication or skin creams; other hygienic and preventive maintenance care.

    Background

    West Virginia Medicaid covers podiatric services that are limited to the examination, diagnosis, treatment, prevention, and care of the foot and ankle when provided by a podiatrist who is licensed and eligible to participate in WV Medicaid. Coverage includes services for acute infections, inflammations, ulcers, specified surgeries of the foot, fracture and dislocation management, treatment of symptomatic structural conditions, debridement for documented mycotic nails with impaired ambulation, orthotics where indicated, and related laboratory and radiology services within the podiatrist’s scope.

    Policy Summary
    PayerWest Virginia Bureau for Medical Services (Department of Human Services)
    PolicyPodiatry (Foot and Ankle) Services Coverage Criteria
    Policy CodePolicy Policy 519.13.1
    Change TypeNo material changes
    Effective DateJan 1, 2022
    Last ReviewJan 1, 2022
    Next Review Date
    Key ActionSubmit all requests for services requiring prior authorization via the BMS utilization management contractor's web-based portal.
    SourceLink
    On This Page
    Coverage Criteria for Podiatric ServicesCoding, Modifiers, and ClassificationProvider Actions, Prior Authorization & DocumentationDefinitionsBackground
    Permitted foot care types: Cutting or removal of corns or calluses; trimming, cutting, clipping, or debriding of toe nails when severity criteria are met

    Severity must be supported by pertinent clinical findings and treating practitioner documentation

    Referral requirement: A written referral to the podiatrist from an enrolled practitioner who treated the member within the past six months must be included in the medical record

    Includes inpatient and nursing home residents

  1. Document clinical findings that meet Class A/B/C severity definitions when billing foot care services.
    2. Documentation Required

    Maintain medical necessity, culture, severity, and orthosis justification in records

    Document medical necessity in the podiatry record for all services, including laboratory culture results for mycotic nails when debridement is performed, severity/class findings for foot care, and justification for custom fabricated orthoses versus prefabricated devices.

    • Retain a laboratory culture report that documents the specific organism identified for mycotic nail debridement.
    • Record clinical findings that establish severity per Class A/B/C definitions when providing covered foot care.
    • Keep documentation supporting the medical necessity of custom fabricated orthoses in the podiatrist's records and make it available to BMS upon request.
    • Include a written referral from an enrolled practitioner within the past six months in the medical record for foot care services.
    Denial Risk

    Denial risk if PA not obtained; limited retrospective authorization

    Services that require prior authorization but are not submitted to the UMC may be denied; retrospective authorization is limited to specific circumstances (a service/procedure denied by the member's primary payer after exhausting their appeal process, or retroactive WV Medicaid eligibility).

    • Do not assume claims lacking prior authorization will be approved—failure to obtain required PA may result in denial.
    • Retrospective authorization is only available when the primary payer denied the service after required appeals, or when there is retroactive Medicaid eligibility; follow Chapter 100 for details.
    Coverage noteRoutine foot care is considered services performed in the absence of localized illness, injury, or symptoms and is addressed separately in coverage criteria and exclusions.
    Podiatric Services
    ScopeFoot and ankle services provided by a podiatrist licensed to provide such services in the State of West Virginia.
    Ankle surgery requirementFor provision of ankle surgery, the podiatrist must have hospital privileges granted by the hospital's medical staff credentialing committee.
    Provider typeServices may be prescribed or provided by authorized practitioners including podiatrists as specified in the policy glossary.