March 13, 2008

Medicare Provides Limited Coverage for Footcare

The Medicare statute limits coverage of both medical services and supportive devices related to care of the feet.  Medicare program rules concerning coverage of such items and services are quite detailed, as the following discussion explains.

Items and Services Excluded from Payment

Specific exclusions of footcare coverage set out in the Medicare statute at Social Security Act (S.S.A.) §1862 (42 U.S.C. §1395y).  The exclusions include:

(a)(8) where such expenses are for orthopedic shoes or other supportive devices for the feet, other than shoes furnished pursuant to section 1861(s)(12) [shoes with inserts for diabetics]; [and] . . .

(a)(13) where such expenses are for –

1862(a)(13)(A) the treatment of flat foot conditions and the prescription of supportive devices therefore,

1862(a)(13)(B) the treatment of subluxations of the feet, or

1862(a)(13)(C) routine foot care (including the cutting or     removal of corns or calluses, the trimming of nails, and other  routine hygienic care); . . . .

Note: The Medicare statute does, however, expressly authorize payment for extra-depth and custom molded shoes with inserts for individuals with diabetes.[1] 

Items and Services that May be Covered

A number of exceptions to the statutory exclusions to Medicare footcare coverage are set out in the regulations adopted by the Centers for Medicare & Medicaid Services.  Thus, 42 C.F.R. § 411.15(l)(2) states that the following kinds of footcare are covered by Medicare:

(i)   Treatment of warts is not excluded.

(ii)  Treatment of mycotic toenails may be covered if it is furnished no more often than every 60 days or the billing physician documents the need for more frequent treatment.

(iii) The services listed in paragraph (l)(1) of this section [see generally services described in S.S.A. § 1862(a)(13) above] are not excluded if they are furnished—

(A)  As an incident to, at the same time as, or as a necessary integral part of a primary covered procedure performed on the foot; or

(B)  As initial diagnostic services (regardless of the   resulting diagnosis) in connection with a specific symptom or complaint that might arise from a condition whose treatment would be covered.

The last two provisions for coverage of foot care in certain situations create important paths for obtaining such services.  Medicare beneficiaries can obtain footcare coverage if their physicians explain that the services are part of another covered procedure, or are an initial diagnostic service related to another covered procedure.

Particulars for Obtaining Coverage

The Medicare Benefits Policy Manual (Pub. 100-02) (MBPM) elaborates on the particular procedures for obtaining coverage of various types of foot care.  See http://www.cms.hhs.gov/Manuals/IOM. 

• Therapeutic shoes covered for diabetic individuals include one pair per calendar year of custom-molded or depth shoes, with extra removable inserts or modifications of the shoes themselves.  The need for such shoes must be certified and documented by a physician managing the individual’s comprehensive plan of care, must be prescribed by a podiatrist, and furnished by a podiatrist or other qualified individual.[2] 

• Orthopedic shoes are not usually covered by Medicare, but they are covered when the orthopedic shoe is an integral part of a leg brace.[3] 

• While treatment for subluxations (partial dislocations of joint surfaces, tendons or muscles) of the foot are not covered by themselves, treatment of resulting medical conditions such as osteoarthritis are covered by Medicare.  Treatment of subluxations of the ankle rather than the foot are covered by Medicare.[4] 

The Medicare Benefits Policy Manual also spells out more clearly the circumstances in which exceptions to the exclusion of coverage for routine foot care are allowed.

• Conditions whose diagnoses and treatments would qualify related foot care for coverage include ulcers, wounds, or infections.[5]

• Also covered is foot care that would otherwise be denied as routine (such as cutting corns, calluses or nails) when needed by persons with systemic conditions that result in diminished circulation or sensation.[6]

• Similarly, treatment for otherwise uncovered mycotic nails is covered when a physician documents resulting pain or secondary infection.[7]

• The manual contains a list of metabolic, neurologic, and peripheral vascular diseases that that could justify coverage for routine foot care.[8]

• It also presumes coverage of routine footcare when certain conditions (ranging from amputation of foot to temperature changes) indicative of severe peripheral involvement are being treated by a physician.[9]

Lessons from the Appeals Process

Finally, the Medicare Appeals Council (MAC) has recognized that the statutory restrictions on coverage of footcare are limited to truly routine conditions.  The MAC is part of the Departmental Appeals Board of the United States Department of Health and Human Services, and performs final administrative reviews in Medicare appeals.  It overturned an Administrative Law Judge's decision dismissing an appeal by a beneficiary who suffered from severe plantar kerotoses on both feet.  In its opinion, the MAC pointed to the opinions of numerous specialists stating that the beneficiary’s plantar kerotoses were the worst ever seen, which established that the services provided to him were not routine in nature and so not subject to the exclusion of coverage in the Medicare statute.[10]  This case is instructive in holding that it is not the particular footcare procedure, but the patient’s condition that determines when coverage is excluded as routine.

For more information, please contact Center for Medicare Advocacy consulting attorney

Sally Hart (shart @ medicareadvocacy.org) at (520) 322-0126.  Remove spaces in email.

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