Toenails seem like a simple part of our body to care for, and in many instances this is true. Unfortunately, as we age, several factors conspire to make this seemingly simple task more difficult. The advance of time and years of shoe pressure and minor injury often lead to toenails that are thickened, and differently shaped. Nail fungus infections become more common, further thickening the nails. The body’s ability to bend over to reach the toes decreases, especially when hip or back disease is present, or if the belly is a bit too large. Vision issues can also hamper one’s ability to see the nails safely. When one combines these factors, what is left is nails that standard nail cutters cannot work through, and toes that are too far out of reach to be easily worked on or even seen.
When these problems arise, many people turn to their foot specialists for care, as many people harbor suspicion of the sanitation of nail salons (sometimes rightfully so). Given the age group that most people begin to experience trouble with nail care, Medicare becomes the primary health insurance provider that the physicians must bill to receive payment for their services. The benefits Medicare provides for it’s enrollees is quite extensive, and includes many medical services, tests, and surgical procedures. Many people also assume that this coverage extends into more minor procedures, such as nail and callus care. While universal coverage of things like nail care for difficult-to-treat nails would be ideal, the reality is that Medicare only has a limited amount of monetary resources to pay for health care. The government has to place priorities on certain types of care, and nail care is not high on that list when compared to stroke or fracture care. Medicare’s philosophy on nail services can be essentially described as an unwillingness to cover nail care by a physician (podiatrist generally), even if someone cannot reach their own toenails or has poor vision, as someone outside of the medical community can generally provide this service (family, friend, nail tech). This policy effects many cases of nail and callus care in which medical treatment is sought, and defines such care as non-covered ‘routine foot care’. Medicare will not pay for such a service, and it is unethical and illegal for a physician to knowingly bill Medicare for this service. A cash price is usually set for payment by the physician’s office for this type of service. Medicare enrollees have the right to demand the physician submit a claim to Medicare, but this claim has to be a special code that shows Medicare this service is non-covered, and Medicare will eventually return with a confirmation of this, and the instruction to bill the enrollee a cash cost for this service. This special claim is not required by Medicare, who lets physicians recognize on their own when a service is non-covered, unless the enrollee demands it. The problem with this demand is that this only delays one’s physician from getting paid for their care, sometimes for weeks to months, even though the patient will still have to pay cash in the end. It is an unnecessary delay that is usually only serve as an antagonizing act by a patient on their physician.
Given all this, it is fortunate that there are some very common scenarios that change Medicare’s policy regarding toe nail care. Medicare is very willing to cover nail care when such care, if provided by someone outside of a physician’s office, would possibly lead to harm of that patient. For example, a person who is diabetic or has circulation disease has a greater chance of developing significant wounds and infections from minor skin nicks than someone who is generally healthy. For this reason, if an untrained individual cut their toenails and caused a small skin wound, the patient in question could be significantly harmed. Medicare wants to prevent this, and has set up a list of conditions in which they feel warrant toenail attention by a physician. This list includes the following conditions:
diabetes, arteriosclerosis (confirmed), rheumatoid arthritis, peripheral neuropathy, multiple sclerosis, arteritis, chronic kidney disease, ALS, leprosy, syphilis related nerve disease, beriberi, pellagra, lipidoses, amyloidosis, pernicious anemia, Freidreich’s ataxia, quadriplegia or paraplegia, Refsum’s disease, polyneuritis, toxic myoneural disease, Raynaud’s disease(not phenomenon), erythromelalgia, phlebitis (active), celiac disease, tropical sprue, blind loop syndrome, pancreatic steatorrhea
Unfortunately, the situation is not as simple as strictly having one of these conditions. Certain combinations of symptoms or findings on a medical exam need to be also present in order to justify this greater risk. These include things like thin skin, swelling, poor pulses, poor sensation, a history of amputation, and other various findings that need to be noted by the doctor and categorized into one of three classes. Together, these are known as ‘class findings’. Without their presence, Medicare will not cover some types of nail care, and also will not cover callus care. Adding even more confusion to the mix is the fact that certain qualifying diseases require one to have been to the doctor treating that condition within the last six months prior to the nail care date. Medicare requires the physician treating the nails to submit the exact date the doctor treating the qualifying disease was seen with every claim, or it won’t pay. Finally, the agencies that administer Medicare claims are numerous, each covering several states. There can be slight variation from state to state regarding these coverage policies, creating even more confusion when one moves to a new state and expects the same exact foot care coverage policy.
For those who completely qualify for toenail care, Medicare will pay 80% of the cost of this service, and some Medicare supplemental insurance will pick up the rest. The new HMO-style Medicare advantage plans usually cover 100%, minus any co-pay the plan has in place. Keep in mind that this payment to the physician is often quite low, sometimes under what a nail salon tech may get paid, depending on the regional Medicare carrier administering the program. Callus care reimburses a little bit more, but also carries more risk of complications if improperly performed. Medicare will allow this service to be performed no less than sixty one days apart. For those uncommon individuals whose nails and calluses grow bothersome faster, Medicare offers no other option.
As one can see, there are options for Medicare enrollees to have their toenails cared for by a podiatrist. Unfortunately, the restrictions that follow this care are extensive, and limit the option for medical trimming of toenails to only those with the greatest of risk for complications.
Scott Kilberg DPM