Page 278 - Medicare Benefit Policy Manual

4. Mycotic Nails

In the absence of a systemic condition, treatment of mycotic nails may be covered.

The treatment of mycotic nails for an ambulatory patient is covered only when the
physician attending the patient’s mycotic condition documents that (1) there is clinical
evidence of mycosis of the toenail, and (2) the patient has marked limitation of
ambulation, pain, or secondary infection resulting from the thickening and dystrophy of
the infected toenail plate.

The treatment of mycotic nails for a nonambulatory patient is covered only when the
physician attending the patient’s mycotic condition documents that (1) there is clinical
evidence of mycosis of the toenail, and (2) the patient suffers from pain or secondary
infection resulting from the thickening and dystrophy of the infected toenail plate.

For the purpose of these requirements, documentation means any written information that
is required by the A/B MAC (B) in order for services to be covered. Thus, the
information submitted with claims must be substantiated by information found in the
patient’s medical record. Any information, including that contained in a form letter, used
for documentation purposes is subject to A/B MAC (B) verification in order to ensure
that the information adequately justifies coverage of the treatment of mycotic nails.

D. Systemic Conditions That Might Justify Coverage

Although not intended as a comprehensive list, the following metabolic, neurologic, and
peripheral vascular diseases (with synonyms in parentheses) most commonly represent
the underlying conditions that might justify coverage for routine foot care.

Diabetes mellitus *
Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive
peripheral arteriosclerosis)
Buerger’s disease (thromboangiitis obliterans)
Chronic thrombophlebitis *
Peripheral neuropathies involving the feet -

Associated with malnutrition and vitamin deficiency *
• Malnutrition (general, pellagra)
• Alcoholism
• Malabsorption (celiac disease, tropical sprue)
• Pernicious anemia
Associated with carcinoma *
Associated with diabetes mellitus *
Associated with drugs and toxins *