Diabetic Peripheral Neuropathy with Loss of Protective Sensation (LOPS)

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This decision memorandum announces the agency's intention to issue a National Coverage Decision covering foot care, that would otherwise be considered routine in the absence of localized illness of the feet, for Medicare beneficiaries with peripheral neuropathy with LOPS as provided or under 42 C.F.R. §411.15 (l)(1)(i). The diagnosis of peripheral neuropathy with LOPS due to diabetes mellitus should be established and documented prior to coverage of foot care. Other causes of peripheral neuropathy should be considered and investigated by the primary care physician prior to initiating scheduled foot care for persons with LOPS. LOPS shall be diagnosed through sensory testing with the 5.07 monofilament. Five sites should be tested on the plantar surface of each foot, 18 using the guidelines in the National Institute of Diabetes and Digestive and Kidney Diseases publication "Feet Can Last a Lifetime. 19 " The areas must be tested randomly since the loss of protective sensation may be patchy in distribution, and the patient may get clues if the test is done rhythmically. Heavily callused areas should be avoided. As suggested by the American Podiatric Medicine Association, an absence of sensation at two or more sites out of 5 tested on either foot when tested with the 5.07 Semmes-Weinstein monofilament must be present and documented to diagnose peripheral neuropathy with loss of protective sensation. 20 An examination of the feet every six months shall be covered for individuals with diabetic peripheral neuropathy and LOPS, as long as the beneficiary has not seen a foot care specialist for some other reason in the interim. Although the frequency of foot exams was not specifically addressed in the Litzelman or Patout studies, it appeared that all participants received at least an initial examination and a follow-up visit during the one-year intervention programs. This interval is also suggested for individuals in the moderate-risk category for lower extremity amputations. 21