Clinical UM Guideline

This document addresses the following foot care services: cutting or removal of corns or calluses, trimming, cutting, clipping or debriding of nails (including mycotic and ingrown toenails), and cleaning and soaking of the feet (whirlpool or hydrotherapy).

Note: Benefit language supersedes this document. Foot care services are not a covered benefit under all member contracts/certificates. Please see the text in the footnote of this document regarding Federal and State mandates and contract language, as these requirements or documents may specifically address the topic of foot care services.

Medically Necessary:

I. Foot care services including cutting or removal of corns or calluses, or trimming, cutting, clipping or debriding of nails are considered medically necessary when the following criteria are met:

1. The individual has a systemic condition resulting in circulatory insufficiency or desensitization of the lower extremity including, but not limited to, one or more of the conditions listed below:
   1. Diabetes mellitus; or
   2. Peripheral vascular disease; or
   3. Peripheral neuropathy;
      and
2. The individual is at increased risk of infection or poor wound healing from the underlying medical condition; and
3. Performance of foot care services by a nonprofessional person would put the individual at risk of loss of life or limb; and
4. Foot care services are not provided more frequently than once every 2 months (unless documentation demonstrates clinical appropriateness).

II. Debridement of mycotic nails is considered medically necessary when the individual has:

1. Pain that is unresponsive to conservative management; or
2. Secondary infection resulting from the thickening and dystrophy of the infected toenail plate;
   and
3. Foot care services are not provided more frequently than once every 2 months (unless documentation demonstrates clinical appropriateness).

III. Surgical removal or care rendered as treatment of ingrown toenail(s) is considered medically necessary.

Not Medically Necessary:

Foot care services, including cutting or removal of corns or calluses, or trimming, cutting, clipping or debriding of nails (including mycotic nails) are considered not medically necessary when the criteria above are not met and for all other indications.

Cleaning and soaking of the feet by a medical professional (whirlpool or hydrotherapy) is considered not medically necessary as part of routine foot care.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Medically Necessary:

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.

When services are also Not Medically Necessary:

Foot care services are an integral part of care in individuals with a systemic condition such as a metabolic, neurologic or peripheral vascular disease that may result in diminished circulation or sensation of the legs or feet. Foot care may include the cutting or removal of corns and calluses or the trimming, cutting, clipping or debriding of nails. Other hygienic and preventive maintenance care may include cleaning and soaking the feet, the use of skin creams to maintain skin tone of either ambulatory or non-ambulatory individuals, or any other services performed in the absence of localized illness, injury or symptoms involving the foot.

According to the American Diabetes Association (ADA), diabetes is one of the most common chronic diseases in the United States (U.S.), with approximately 30 million Americans with diagnosed disease. Another 8 million are believed to have undiagnosed disease. Diabetes mellitus is associated with peripheral vascular disease and peripheral neuropathy, both of which may lead to poor wound healing and serious infection from even minor wounds.

Peripheral neuropathy is a common condition that occurs when nerves are damaged or destroyed. Common symptoms include pain, tingling, numbness, stabbing sensations, electric-like sensations, burning sensations and weakness. Individuals with peripheral neuropathy from any cause are at risk for poor wound healing and serious infection from even minor wounds.

In 2024, the ADA published standards of care in diabetes, the committee provided the following recommendations for foot care:

12.23 Perform a comprehensive foot evaluation at least annually to identify risk factors for ulcers and amputations. A
12.24 The examination should include inspection of the skin, assessment of foot deformities, neurological assessment (10-g monofilament testing with at least one other assessment: pinprick, temperature, vibration), and vascular assessment, including pulses in the legs and feet. B
12.24 Individuals with evidence of sensory loss or prior ulceration or amputation should have their feet inspected at every visit. A
12.26 Obtain a prior history of ulceration, amputation, Charcot foot, angioplasty or vascular surgery, cigarette smoking, retinopathy, and renal disease and assess current symptoms of neuropathy (pain, burning, numbness) and vascular disease (leg fatigue, claudication). B
12.27 Initial screening for peripheral arterial disease (PAD) should include assessment of lower-extremity pulses, capillary refill time, rubor on dependency, pallor on elevation, and venous filling time. Individuals with a history of leg fatigue, claudication, and rest pain relieved with dependency or decreased or absent pedal pulses should be referred for ankle–brachial index and for further vascular assessment as appropriate.B
12.28 A interprofessional approach facilitated by a podiatrist in conjunction with other appropriate team members is recommended for individuals with foot ulcers and high-risk feet (e.g., those on dialysis, those with Charcot foot, those with a history of prior ulcers or amputation, and those with PAD). B
12.29 Refer individuals who smoke or have a history of prior lower-extremity complications, loss of protective sensation, structural abnormalities, or PAD to foot care specialists for ongoing preventive care and lifelong surveillance. B
12.30 Provide general preventive foot self-care education to all people with diabetes, including those with loss of protective sensation, on appropriate ways to examine their feet (palpation or visual inspection with an unbreakable mirror) for daily surveillance of early foot problems. B

Based on the typical rate of toenail growth and recurrence rate of corns and calluses foot care services are not usually required more frequently than every 2 months. However, in certain individuals, care may be needed more frequently based on their individual clinical presentation. The clinical records should contain clear documentation of the medical basis for providing foot care services more often than every 2 months.

Debridement of mycotic nails may be clinically appropriate when pain results in difficulty walking and/or abnormality of gait in conventional walking footwear, or in non-ambulatory individuals, when there is pain unresponsive to conservative therapy. In addition, debridement may be clinically appropriate when there is secondary infection resulting from the thickening and dystrophy of the infected toenail plate. Unless documentation demonstrates clinical appropriateness, debridement of mycotic nails is not required more frequently than once every 2 months.

Ingrown toenails are common and occur either when the skin grows over the side of the toenail or when the toenail grows into the skin. They can cause pain, discomfort, and infection. Surgical treatment for ingrown toenails may include removal of part of the nail or the entire nail, removing part of the underlying nailbed, or removing part of the soft tissue adjacent to the toenail. Treatment may also include excision of the nail and nail matrix, resulting in permanent removal of the nail.

Cleaning and soaking the feet (whirlpool or hydrotherapy) are considered hygienic and preventive maintenance but do not provide a clinically meaningful benefit.

The document is based on peer-reviewed published literature, professional, and podiatric and medical organizational input regarding generally accepted standards of medical practice, and current ADA standards.

Peer Reviewed Publications:

1. O'Connor JJ, Deroche CB, Wipke-Tevis DD, et al. Foot care self-management in non-diabetic older adults: A pilot controlled trial. West J Nurs Res. 2021; 43(8):751-761.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Diabetes Association. Standards of Care in Diabetes–2023. Diabetes Care 2024; 47(Suppl 1):S12-S321.
2. Bus SA, Armstrong DG, van Deursen RW, et al. International Working Group on the Diabetic Foot. IWGDF guidance on footwear and offloading interventions to prevent and heal foot ulcers in patients with diabetes. Diabetes Metab Res Rev. 2016a; 32 Suppl 1:25-36.
3. Bus SA, van Deursen RW, Armstrong DG, et al. International Working Group on the Diabetic Foot (IWGDF). Footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in patients with diabetes: a systematic review. Diabetes Metab Res Rev. 2016b; 32 Suppl 1:99-118.
4. Lewis J, Lipp A. Pressure-relieving interventions for treating diabetic foot ulcers. Cochrane Database Syst Rev. 2013; (1):CD002302.
5. van Netten JJ, Price PE, Lavery LA, et al. International Working Group on the Diabetic Foot (IWGDF). Prevention of foot ulcers in the at-risk patient with diabetes: a systematic review. Diabetes Metab Res Rev. 2016; 32 Suppl 1:84-98.

1. American Academy of Orthopaedic Surgeons (AAOS). OrthoInfo. Ingrown toenail. Last reviewed May 2024. Available at: https://orthoinfo.aaos.org/en/diseases--conditions/ingrown-toenail/. Accessed on October 28, 2024.
2. American Diabetes Association. Standards of Care in Diabetes-2023. Available at: https://diabetesjournals.org/care/issue/46/Supplement_1. Accessed on August 6, 2024.
3. American Diabetes Association. Diabetes complications. Available at: https://diabetes.org/diabetes/foot-complications. Accessed on October 28, 2024.
4. American Diabetes Association. Peripheral neuropathy. Available at: https://diabetes.org/diabetes/neuropathy/peripheral-neuropathy. Accessed on October 28, 2024.
5. National Institutes of Health. Peripheral neuropathy. Available at: https://www.ninds.nih.gov/health-information/disorders/peripheral-neuropathy. Accessed on October 28, 2024.