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Medical Policy Revision: Foot Care Services

Effective January 4, 2016, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for routine foot care services provided to diabetic patients.

According to the guidelines of our medical policy, Foot Care Services:

  • Paring or cutting of benign hyperkeratotic lesions of the foot (e.g., corns, calluses) and trimming or debridement of toenails are usually performed by non-medical professional members and do not require the skills of a qualified medical provider of foot care services, and as such, are generally considered not medically necessary.

     
  • For members in whom paring or cutting of corns and calluses, or trimming of toenails would be hazardous when performed by non-medical professional members, it is considered medically necessary when the following criteria are met.
    • The service is performed by a qualified medical provider of foot care services; and
    • The member has a systemic condition which may result in severe circulatory embarrassment (compromise) or diminished sensation in the feet, including, but not limited to, the following:
      • Diabetes mellitus (with or without complications);
      • Arteriosclerosis obliterans and peripheral vascular disease;
      • Buerger’s disease;
      • Chronic thrombophlebitis;
      • Neuropathies involving the feet which may be associated with diabetes mellitus, pernicious anemia, uremia, multiple sclerosis, hereditary sensory radicular neuropathy, malabsorption, leprosy and neurosyphilis, amyloid neuropathy or pellagra.
  • Additionally, debridement of toenails is considered medically necessary when the following criteria are met:
    • The service is performed by a qualified medical provider of foot care services; and
    • The member has clinical evidence of onychomycosis (mycotic nails) confirmed by positive culture or by documented signs and symptoms; or onychauxis (club nail), onychogryphosis (deformed nail), or onogryphosis (thickened nail) associated with infection or pain from gross distortions of the nail.

Based on the guidelines included in our revised medical policy, Foot Care Services, AND the submitted diagnosis or diagnoses code(s), HCPCS code G0247 submitted on claims for services provided on and after January 4, 2016 may be denied as not medically necessary.

Review this revised policy in our online Medical Policy Manual.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service January 4, 2016 and after.

Published on: October 2, 2015, 12:48 p.m. ET
Last updated on: November 24, 2020, 23:44 p.m. ET