The Sentinel, a publication of the SMP Resource Center
www.smpresource.org
August 2015
Medicare’s Limited Coverage for Podiatry Services
By Mike Klug
SMP Resource Center Consultant
T
he 2015 Medicare & You handbook generally does a good job of summarizing Medicare’s options, benefits,
and costs. But when it comes to podiatry services, the description of Medicare’s foot care benefits found on
page 49 probably raises more questions than it answers. Under the heading “Foot exams and treatments,” the
handbook succinctly states that “Medicare covers foot exams and treatment if you have diabetes-related nerve
damage and/or meet certain conditions.” What are those “certain conditions” and what sort of treatment will
Medicare pay for? Beneficiaries sometimes bring these and other questions about Medicare’s coverage for
podiatry services to SMPs. They’re not always easy to answer.
What is Podiatry?
There are approximately 11,000 licensed podiatrists, or Doctors of Podiatric Medicine (DPM), in the United
States. Medicare classifies them as physicians who can receive Part B payments for providing care limited to the
diagnosis and treatment of conditions of the foot and ankle. Podiatrists use noninvasive medical and surgical
procedures to treat conditions such as corns, bunions, plantar warts, fungal infections, subluxations, sports
injuries, and diabetic ulcers. They also trim toenails. In the course of a year, more Medicare beneficiaries visit
podiatrists than chiropractors and psychiatrists combined. More than 6 million beneficiaries received Medicarecovered podiatry services in 2012, with approved payment amounts totaling more than $2 billion.
The Routine Foot Care Exclusion
One of the main sources of confusion about Medicare’s foot care benefit is the “routine foot care exclusion.” In
practice, Medicare covers routine foot care for beneficiaries with certain serious health conditions. In general,
however, Medicare excludes routine foot care from coverage.
The Medicare Benefit Policy Manual, Chapter 15, describes the following services as routine and not covered:

Cutting or removing corns and calluses

Trimming, cutting, and clipping nails

Other hygienic and preventive maintenance care such as cleaning and soaking, or the use of skin creams
to maintain skin tone

Any other service performed in the absence of localized illness, injury, or symptoms involving the foot
continued
Medicare also excludes coverage treatment of flat feet, and it generally doesn’t pay for arch supports, other
supportive devices for the feet, and orthopedic shoes. The exceptions are for a shoe that “is an integral part of a
leg brace” and therapeutic shoes for people with diabetes. Medicare also doesn’t pay to treat subluxated
structures of the foot defined as partial dislocations or displacements of joint surfaces, tendons, ligaments, or
muscles. But it does cover treatments for subluxations in the ankle joint and treatment for partial joint
displacements in the foot caused by conditions like osteoarthritis.
Exceptions to the Exclusion
The Medicare Benefit Policy Manual lists four main exceptions to the routine foot exclusion. The Medicare &
You handbook alludes to one of them (the exception for the presence of a systemic condition like diabetes):
1. Necessary and Integral Exception. In some cases, Medicare covers routine foot care services if they comprise
“a necessary and integral part” of other covered services such as treatment of ulcers, wounds, or infections.
2. Warts Exception. Medicare covers treatment of warts on the feet, including plantar warts, “to the same extent
as services provided for the treatment of warts located elsewhere on the body.” Medicare covers the treatment
and removal of symptomatic warts.
3. Mycotic Toenail Exception. Mycosis is a communicable fungal infection that often causes discoloration and
thickening of the toenails. Serious infections may cause the toenail to separate from the nail bed and cause
pain and difficulty walking. Medicare does cover the treatment of mycotic toenails in the absence of a systemic
condition like diabetes or peripheral neuropathy but only when the clinical record contains evidence of the
presence of mycosis in the nail and the patient experiences pain or difficulty walking or develops a secondary
infection in the toenail plate. Usually, though, Medicare will likely view the treatment of mild fungal infections
as routine foot care. In more severe cases, Medicare covers the debridement of mycotic toenails – a cutting or
grinding procedure used to thin degenerating toenails and alleviate pain. Some Medicare Administrative
Contractors (MACs) also have issued Local Coverage Determinations (LCDs) that further detail the coverage
criteria for podiatric services like mycotic toenail debridement.
4. Presence of a Systemic Condition Exception. Beneficiaries with a systemic condition that decreases circulation
or sensation in the legs and feet may require podiatry services that otherwise would be considered routine.
Thus, Medicare will pay for cutting or removing corns and calluses and clipping or trimming toenails for
patients with certain metabolic, neurologic, and peripheral vascular diseases. The Medicare Benefit Policy
Manual lists several systemic conditions that might make it medically necessary for podiatrists to provide
routine foot care services for these beneficiaries. Along with other conditions, the list includes:

Diabetes mellitus

Arteriosclerosis of the extremities

Chronic thrombophlebitis

Peripheral neuropathies associated with malnutrition and vitamin deficiency, cancer, multiple sclerosis,
traumatic injury, and hereditary disorders
continued
CMS (Centers for Medicare & Medicaid Services) guidance also instructs MACs to presume that Part B coverage
applies to routine foot care services when they find that part of a foot has been amputated or when the pulse in a
patient’s leg or foot is absent and severe swelling, burning, or abnormal sensations appear in the feet.
When people wonder why Medicare covers podiatry services for some beneficiaries and not for others, SMPs
can help clear up the confusion and unwarranted concerns about fraud and abuse by explaining the four important
exceptions to Medicare’s routine foot care exclusion. 
This newsletter was supported in part by a grant (No. 90NP0003) from the Administration for Community Living (ACL), U.S. Department of Health and Human
Services (DHHS). Grantees carrying out projects under government sponsorship are encouraged to express freely their findings and conclusions. Therefore,
points of view or opinions do not necessarily represent official ACL or DHHS policy.