Toenails seem like a simple part of our body to take care of, and in many cases, it is. Unfortunately, as we age, there are several factors that combine to make this seemingly simple task more difficult. The passage of time and years of shoe pressure and minor injuries often results in thick and differently shaped nails. Fungal nail infections become more common, further thickening the nails. The body’s ability to bend over to reach the toes decreases, especially with hip or back disease, or if the stomach is a little too big. Vision problems can also hamper a person’s ability to see nails safely. When these factors are combined, only nails remain that standard nail clippers cannot pass through and toes that are too far out of reach to be easily worked on or even seen.
When these issues arise, many people turn to their foot specialists for care, as many people are wary of nail salon sanitation (sometimes rightly so). Given the age group at which most people begin to have issues with nail care, Medicare is becoming the primary health insurance provider that doctors must bill to receive payment for their services. The benefits offered by Medicare to its registrants are quite extensive and include many medical services, tests and surgeries. Many people also assume that this coverage extends to more minor procedures, such as nail and callus care. While universal coverage of things like nail care for hard-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 must prioritize certain types of care, and nail care is not at the top of this list when compared to stroke or fracture care. Medicare’s philosophy on nail services can be basically described as a reluctance to cover nail care by a doctor (chiropodist in general), even if someone cannot reach their own nails or has poor vision, because someone outside of the medical community can usually provide this service (family, friend, nail tech). This policy covers many cases of nail and callus care for which medical treatment is sought, and defines such care as “routine foot care” not covered. 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 doctor’s office for this type of service. People enrolled in Medicare have the right to require the doctor to submit a claim to Medicare, but that claim must be a special code telling Medicare that this service is not covered, and Medicare will eventually come back with confirmation. that and the instruction to invoice. the enrolled a cash cost for this service. This special request is not required by Medicare, which allows physicians to identify themselves when a service is not covered, unless the member requests it. The problem with this request is that it only delays the doctor from being paid for their care, sometimes for weeks or even months, although the patient will still have to pay cash at the end. It is an unnecessary delay which is generally only an antagonistic act of a patient towards his doctor.
Given all of this, it is fortunate that there are some very common scenarios that change Medicare policy regarding toenail care. Medicare is more than willing to cover nail care when such care, if provided by someone outside of a doctor’s office, could potentially harm that patient. For example, a person with diabetes or a circulatory disease is more likely to develop sores and significant infections from minor cuts in the skin than a generally healthy person. Because of this, if an untrained person cuts their toenails and causes a small sore on the skin, the patient in question could be seriously injured. Medicare wants to prevent this and has drawn up a list of conditions under which they say a doctor should treat toenails. 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 disease, polyneuritis, toxic myoneural disease, Raynaud’s disease (non-phenomenon), erythromelalgia, phlebitis (active), celiac disease, tropical sprue, blind loop syndrome, pancreatic steatorrhea
Unfortunately, the situation is not as simple as having strictly one of these conditions. Certain combinations of symptoms or results of a medical examination must also be present in order to justify this increased risk. These include things like thin skin, swelling, poor pulse, bad feeling, history of amputation, and other miscellaneous findings that should be noted by the doctor and classified into one of three classes. Together they are known as “class findings”. Without them, Medicare will not cover certain types of nail care, nor will it cover callus care. Adding even more confusion to the mix is the fact that some qualifying conditions require having been to the doctor treating that condition within the last six months prior to the nail care date. Medicare requires the doctor treating the nails to provide the exact date the doctor treating the qualifying disease was seen with each claim, otherwise they will not pay. Finally, there are many agencies that administer health insurance claims, each covering multiple states. There may be slight variations from state to state when it comes to these coverage policies, creating even more confusion when moving to a new state and expecting the same policy. foot care blanket.
For those who fully qualify for nail care, Medicare will pay 80% of the cost of this service, and some Medicare supplemental insurance will pay the rest. New HMO-style Medicare benefit plans typically cover 100%, less any copayments of the plan in place. Keep in mind that this payment to the doctor is often quite low, sometimes below what a nail salon technician can be paid, depending on the regional health insurance carrier administering the program. Callus care reimburses a little more, but also carries a greater risk of complications if done incorrectly. Medicare will allow this service to be performed at least sixty-one days apart. For those rare people whose nails and calluses grow faster, Medicare offers no other options.
As can be seen, there are options for people on Medicare to have their nails treated by a podiatrist. Unfortunately, the restrictions following this care are extensive and limit the option of medical nail trimming to those at greatest risk of complications.