Toenails seem like a simple part of our body to take care of, and in many cases this is true. Unfortunately, as we age, several factors conspire to make this seemingly simple task more difficult. Advancing time and years of shoe pressure and minor injuries often lead to thickened and differently shaped toenails. Fungal nail infections become more common and further thicken the nails. The body’s ability to bend down to reach the toes decreases, especially when there is hip or back disease, or if the belly is too large. Vision problems can also hinder one’s ability to see the nails safely. When one combines these factors, what you are left with are nails that standard nail cutters can’t cut and toes that are too out of reach to work with or even see easily.
When these problems arise, many people turn to their foot specialists for care, as many people are suspicious about nail salon sanitation (sometimes rightly so). Given the age group in which most people begin to experience problems with nail care, Medicare becomes the main health insurance provider that doctors must bill to receive payment for their services. The benefits that Medicare provides for its enrollments are quite extensive and include many medical services, tests, and surgical procedures. Many people also assume that this coverage extends to minor procedures, such as nail care and calluses. While universal coverage for things like hard-to-treat nail care would be ideal, the reality is that Medicare only has a limited amount of money to pay for health care. The government has to prioritize certain types of care, and nail care isn’t high on that list compared to care for strokes or fractures. Medicare’s philosophy on nail services can essentially be described as an unwillingness to cover nail care by a physician (podiatrist in general), even if someone can’t reach their own toenails or has vision problems, as someone outside the medical community can usually provide this service (family, friend, nail technician). This policy affects 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 this service, and it is unethical and illegal for a doctor to knowingly bill Medicare for this service. Usually, a cash price is set for payment by the doctor’s office for this type of service. Medicare enrollees have the right to demand that the doctor submit a claim to Medicare, but this claim must be a special code showing that Medicare does not cover this service, and Medicare will eventually return with confirmation of this and instructions for billing. the affiliate has a cash cost for this service. This special claim is not required by Medicare, which allows physicians to self-report when a service is not covered, unless the member requires it. The problem with this lawsuit is that it only delays the doctor from receiving payment for their care, sometimes for weeks or months, even though the patient will have to pay cash in the end. It is an unnecessary delay that usually only serves as an act of antagonism on the part of a patient towards her doctor.
Given all of this, it’s fortunate that there are some very common scenarios that change Medicare’s policy regarding toenail care. Medicare is very willing to cover nail care when such care, if provided by someone outside of a doctor’s office, could cause harm to the patient. For example, a person who is diabetic or has a circulatory disease is more likely to develop significant wounds and infections from minor breaks in the skin than someone who is in generally good health. For this reason, if an untrained person cuts their toenails and causes a small skin wound, the patient in question could suffer significant harm. Medicare wants to prevent this, and has established a list of conditions that it considers toenails warrant a doctor’s attention. 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, lipidosis, amyloidosis, pernicious anemia, Freidreich’s ataxia, quadriplegia or paraplegia, Refsum disease, polyneuritis, toxic myoneural disease, Raynaud’s disease (nonphenomenon), 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 must also be present to justify this increased risk. These include things like thin skin, swelling, poor pulses, poor sensation, a history of amputation, and various other findings that the doctor should note and classify into one of three classes. Collectively, these are known as “class findings.” Without your presence, Medicare won’t cover some types of nail care, and it won’t cover callus care. Adding even more confusion to the mix is the fact that certain qualifying illnesses 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 nail doctor to submit the exact date the doctor treating the qualifying condition was seen with each claim, or Medicare won’t pay. Finally, the agencies that handle Medicare claims are numerous, each covering multiple states. There may be a slight variation from state to state regarding these coverage policies, creating even more confusion when one moves to a new state and expects the exact same foot care coverage policy.
For those who fully qualify for toenail care, Medicare will pay 80% of the cost of this service and some Medicare supplement insurance will cover the rest. The new HMO-style Medicare Advantage plans generally cover 100%, less any copays the plan has. Keep in mind that this doctor’s payment is often quite low, sometimes below what a nail salon technician can be paid, depending on the regional Medicare company that administers the program. Callus care pays back a bit more, but it also carries a higher risk of complications if done incorrectly. Medicare will allow this service to be performed no less than sixty-one days apart. For those unusual people whose nails and calluses get annoying faster, Medicare offers no other option.
As you can see, there are options for those enrolled in Medicare to have their toenails taken care of by a podiatrist. Unfortunately, the restrictions that follow this care are extensive, limiting the option of medical toenail clipping to only those with the highest risk of complications.