Surgical Treatment of Nails

Jurisdiction: JL MAC Part B. States: Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania. Type: Active LCD

Compliance with the provisions in this LCD may be monitored and addressed through post payment data analysis and subsequent medical review audits. History/Background and/or General Information There are a number of indications for surgical exploration of the nail unit of the fingers and toes. Surgical nail avulsion may be performed to aid in diagnosis by allowing for the full examination and exploration of the nail bed, the nail matrix, the proximal nail fold (the soft tissue that protects the emerging nail plate), the lateral nail fold (LNF) (extension of the proximal nail fold that protects each side of the nail plate), and the nail grooves for the presence of pathology or as a preliminary step before performing a biopsy on the nail bed and the nail matrix. Indications such as subungual hematomas and tumors, benign or malignant neoplasms and trauma may require access and visualization of the nail bed. Surgical nail avulsion may also be performed for therapeutic management of disease processes, to relieve pain or to correct or prevent anatomical deformities of the nail. Symptomatic disease processes affecting the nail complex that may be managed with surgical intervention include infections, inflammation, onychomycosis (i.e., fungal infection), onychocryptosis (i.e., ingrown nails), onychogryphosis (i.e., hornlike hypertrophy of the nail plate), and onychauxis (i.e., thickened nails), as well as psoriasis, lichen planus, congenital nail dystrophies, 1 and tumors. 2 Nail treatment and surgical options must be individualized based on the nail condition and careful consideration should be taken when selecting patients for surgical nail procedures. Factors to consider when determining appropriate treatment include the extent of disease, type of organism, and medical comorbidities. 1 Patients with factors that predispose them to infection include but are not limited to those with uncontrolled diabetes mellitus, prior infection with methicillin-resistant Staphylococcus aureus, and immunosuppression. Medical conditions that impede blood flow or depress immunity may increase the risk of fungal nail infection. Diabetes and circulatory disorders may impair blood flow to the nail beds, increasing the chance of fungal infection. Prevalence in the general population ranges from 2.5% - 5% and is more common in diabetics (13% - 32%). Diabetics, and others suffering from impaired arterial circulation and decreased sensation, may present with more severe cases (i.e., secondary infection, gangrene). 3,4,5 Ingrown toenails account for approximately 20% of foot problems presented in the primary care setting. 6 An ingrown nail is a condition which results in the growth of the nail edge into the surrounding soft tissue that may result in pain, inflammation, or infection. This condition, although not very often, may involve the fingernails, and is noted in the literature to commonly occur in the great toes. 1,6 No consensus has been reached for the best treatment approach, but ingrown nails may be treated non-surgically or surgically. Non-surgical treatments are typically used for mild to moderate ingrown nails, whereas surgical treatments are typically used in moderate and severe cases. 1,3,6 Blood underneath a fingernail or toenail or a subungual hematoma, generates pressure between the nail bed and the nail plate where the blood collects and may cause pain. Treatment of a subungual hematoma depends on the type of injury and patient comorbidities or risk factors for complications. A small not too painful hematoma is incorporated into the nail and progressively migrates outward to the free edge of the nail plate as the nail grows out. In traumatic nail injuries, surgical nail avulsion may be used to evaluate the stability of the nail bed or to release a subungual hematoma after a failed puncture aspiration. Injury of a fingernail may be treated with avulsion with surgical repair of the nail bed. 1,10 For toenail avulsions, a nonadherent, highly absorbent dressing is ideal. 10 A reattachment of the avulsed fingernail or a fingernail substitute, intended to protect the nail bed during the healing process, will adhere to the nail bed within 1 to 3 months and will be pushed off by the new nail, and as noted in this situation, will reach complete growth in 4 to 6 months. 8 The thickening of the nail plate may be a symptom of nail fungus, psoriasis or other conditions. This thickening (Onychauxis) may force the nail plate to separate from the nail bed (Onycholysis). This condition may last for several months because the finger or toenail will not reattach to its nail bed. Non-surgical treatment consists of clipping off the affected separated portion at the distal end of the of the nail plate and treating the underlying cause. In the case of moderate or severe symptomatic dystrophic nail plate, a surgical intervention may be required. 1,3,6 A partial or complete avulsion of a nail plate is generally performed under local anesthesia. This surgical procedure involves the separation and a partial removal of a border of the nail plate or removal of the entire nail plate from the nail bed to the eponychium; the surgical removal of the body of the nail plate from its primary attachments, the nail bed ventrally and the proximal nail fold dorsally. Excision of nail plate and nail matrix is performed under local anesthesia and requires removal of the full length or the entire nail plate, with destruction or permanent removal of the matrix (matrixectomy). Matrixectomy can be performed surgically, chemically, electrosurgically, or with radiofrequency ablation. All are effective options when treating ingrown toenails. 6 Partial matrixectomies may be performed in the management of persistent onycholysis and onychocryptosis. When performed without matrixectomy, in most cases, the nail will regrow from the area under the cuticle (the matrix). A fingernail takes about 4 to 6 months to grow back. A toenail takes about 8 to 12 months to grow back. 7,8 Wedge excision of skin of the nail fold is designed to relieve pressure on the nail/soft tissue and is an excision of the skin from the involved, medial and/or lateral, side of the toe or finger. The technique of wedge excision often fails to remove the nail spicule. Nail removal without destroying the matrix of the nail that produces nail growth can permit the nail to regrow beneath the nail fold, producing another ingrown nail. The purpose of partial or complete removal of a nail is to decrease the width of the nail plate at the offending border to relieve pain and pressure. This procedure could include removal/destruction of the nail matrix, either surgically or chemically, to cause long-term narrowing of the nail plate. 3,6 Covered Indications Avulsion of the nail plate, excision of the nail and nail matrix, and wedge excision of the skin of the nail fold are considered medically reasonable and necessary for the following indications: Symptomatic onychocryptosis (ingrown fingernails or toenails) 1,4,7,8 Subungual abscess and/or hematoma 7,9,10 Subungual and periungual tumors 2,9 Injury of the toes or fingers involving the nail component to evaluate the stability of the nail bed or to release a subungual hematoma after a failed puncture aspiration 1,7,11 Severe or recurrent fungal nail infection that has failed to respond to usual, less invasive treatment (for example, pharmacological treatment, debridement) For diagnosis of suspected lichen planus or psoriasis of the fingernail or toenail 2, 9,10 Onychogryphosis or onychauxis 1 Congenital or acquired nail dystrophies that jeopardize the integrity of the finger or toe 1,2,10 Limitations The following are considered not medically reasonable and necessary: Nail debridement or removing small chips or wedges of the nail and/or skin that does not require local anesthesia does not constitute surgical treatment of a nail 3,6,11 Trimming, cutting, or clipping of the distal unattached nail margins does not constitute surgical treatment of a nail 3,6,11 Surgical treatment of asymptomatic conditions 3,6 Repeat nail avulsion on the same toe or finger following a complete nail avulsion performed more frequently than every 8 months (32 weeks) for toenails or 4 months (16 weeks) for fingernails 7,10 Repeat nail excision on the same toe or finger following a complete nail excision for permanent removal Provider Qualifications Services will be considered medically reasonable and necessary when all aspects of care are within the scope of practice of the provider’s professional licensure, when performed according to the supervision requirements per state scope of practice laws, and when all procedures are performed by appropriately trained providers in the appropriate setting. Notice : Services performed for any given diagnosis must meet all of the indications and limitations stated in this LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.