August 20, 2018

Since last November, APMA has been working with our Novitas Carrier Advisory Committee (CAC) representatives to clarify problematic language in Novitas’ Mycotic Nail Debridement Local Coverage Determination (LCD). As a result of the work of APMA and the CAC representatives, Novitas has changed the language, releasing a new LCD with an effective date of August 16, 2018. Under this new LCD, if the patient qualifies under “mycotic nail debridement” and debridement is performed without concomitant pharmacologic therapy, mycologic confirmation is expected. This change is unrelated to patients who qualify for nail care under the Novitas “Routine Foot Care” LCD, which makes no mention of mycologic confirmation.

The previous language was as follows:

Onychomycosis may present as one or more nail findings, including hypertrophy/thickening, lysis, discoloration, brittleness or loosening of the nail plate. Fungal disease of the toenails is usually a relatively benign condition and may produce little or no symptoms beyond white opacities on the nails. Confirmation of mycotic nail infections by laboratory tests such as fungal cultures and/or stains is not necessary for Medicare coverage of debridement when clinical findings are strongly supportive of the diagnosis and treatment is not contraindicated. Mycologic confirmation by culture, potassium hydroxide examination, or dermatophyte testing to differentiate fungal disease from other nail pathology may be required for Medicare payment of mycotic nail debridement in some circumstances such as previous unsatisfactory treatment results (recurrent nail disease, unsuccessful treatment with FDA approved antifungal medications, long term - beyond 12 debridements per 24 months, etc.) and for patients whose debridement is prescribed absent of concomitant pharmacologic therapy, such as for patients deemed to be too high risk for oral antifungal medication use.

In the new LCD that language has been changed to:

Onychomycosis may present as one or more nail findings, including hypertrophy/thickening, lysis, discoloration, brittleness or loosening of the nail plate. Fungal disease of the toenails is usually a relatively benign condition and may produce little or no symptoms beyond white opacities on the nails. Confirmation of mycotic nail infections by laboratory tests such as fungal cultures and/or stains is not necessary for Medicare coverage of debridement when clinical findings are strongly supportive of the diagnosis and treatment is not contraindicated. For coverage of mycotic nail debridement, mycologic confirmation by culture, potassium hydroxide examination, or dermatophyte testing is expected to differentiate fungal disease from other nail pathology in certain circumstances including but not limited to the following conditions: previous unsatisfactory treatment results (recurrent nail disease, unsuccessful treatment with FDA approved antifungal medications, long term - beyond 12 debridements per 24 months, etc.) and for patients whose debridement is prescribed absent of concomitant pharmacologic therapy.

This change is small but critical. It provides clear direction as to what documentation and steps our members must take in order for their patients to be covered and for our members to be fairly and efficiently reimbursed.

If you have questions about this issue, please contact the APMA Health Policy and Practice Department at healthpolicy.hpp@apma.org or your CAC representative.

Having an issue with your Medicare reimbursements and not sure who your CAC representative is? Visit the CAC-PIAC page and look up your state CAC representative today!