Surgical Treatment of Nails

Jurisdiction: JM Part B. States: North Carolina, South Carolina, Virginia, West Virginia. Type: Active LCD

Nail surgery is often performed to remove benign and malignant nail tumors, relieve pain caused by ingrown and traumatized nails, manage disease processes, and diagnose challenging lesions and dystrophies. 8 An ingrown nail (onychocryptosis) is a condition which results in the growth of the nail edge into the surrounding soft tissue. Ingrown toenails present with a varying degree of inflammation and edema of the nail folds. This often results in a draining, foul-smelling lesion with hypertrophy of the involved nail fold; however, the most common accompanying symptom is pain. This condition most commonly occurs in the great toes and may require surgical treatment in moderate to severe cases. 7,10,13 Ingrown toenails account for approximately 20% of foot problems presenting to primary care. 13 Other conditions may also require avulsion of part or all the nail. These conditions may include but are not limited to onychomycosis, subungual hematoma, trauma, onychogryphosis, psoriasis, lichen planus, congenital nail dystrophies, and tumors. 1,2,5,12,14 Onychauxis, which can result from nail fungus, psoriasis, or other conditions, may cause onycholysis (separation of the nail plate from the nail bed). In the case of a moderate to severe symptomatic dystrophic nail plate, surgical intervention may be needed. 5,7,12 This LCD addresses the conditions for which nail avulsion may be considered reasonable and necessary. Surgical techniques for the treatment of nail pathology include complete or partial nail avulsion. Nail avulsion requires adequate anesthesia for optimal results. 11 Generally, this procedure is performed under local anesthesia and involves the separation and removal of a border of the nail or removal of the entire nail from the nail bed to the eponychium. 8 When possible, partial nail plate avulsion is preferred to complete avulsion, because it minimizes trauma to the adjacent tissues. 3 Nail avulsions usually offer only temporary relief for ingrown toenails. The nail often grows back to its original thickness, and the offending margin again may become problematic, resulting in a need for another nail avulsion. Often, the preferred course of treatment may be a partial or complete nail avulsion performed with a matrixectomy, which is destruction or permanent removal of the matrix to prevent the nail from regrowing. 6,9,13,17 The matrixectomy can be performed either chemically or surgically. When nail avulsion is performed without matrixectomy, the nail will regrow from the matrix. 4 A fingernail takes approximately 4–6 months to regrow, and a toenail takes approximately 8–12 months to regrow. 1,13,14,16 Wedge excision of skin of the nail fold is a procedure designed to relieve pressure on the nail/soft tissue and requires an excision of a wedge of the soft granulation tissue and ingrown nail from the affected side (medial and/or lateral) of the toe or finger. 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. Covered Indications Surgical treatment of nails is covered for the following indications: Symptomatic onychocryptosis (ingrown fingernails or toenails) 6,7,10,13,15,17 ; Subungual abscess and/or hematoma after a failed puncture aspiration; Complicated injury of the toes or fingers involving the nail component that is severe enough to require removal of the nail to evaluate the stability of the nail bed or to release a subungual hematoma 14 ; Severe or recurrent fungal nail infection that has failed to respond to usual, less invasive treatment (e.g., pharmacological treatment, debridement); Onychogryphosis or onychauxis 1 ; Congenital or acquired nail dystrophies that jeopardize the integrity of the finger or toe 1,8 ; Diagnosis of suspected lichen planus or psoriasis of the fingernail or toenail 1 ; Subungual and periungual tumors 5 For a medically reasonable and necessary repeat nail excision on the same finger or toe. The medical record documentation must be specific as to the indication, such as ingrown nail of the opposite border or new significant pathology on the same border recently treated; For a medically reasonable and necessary repeat nail avulsion of the same toenail or fingernail performed more often than every 32 weeks (8 months) for toenails or every 16 weeks (4 months) for fingernails. The medical record documentation must be specific as to the indication, such as ingrown nail of the opposite border or new significant pathology on the same border recently treated. 1,13,14,16 Limitations The following indications are non-covered and are considered not medically reasonable and necessary: Trimming, cutting, clipping or debridement of nails; Removing small chips or wedges of the nail or skin that does not require local anesthesia does not constitute surgical treatment of a nail 1,13 ; Simple treatment of ingrown toenails (e.g., trimming, cutting, clipping of the distal unattached nail margins) does not constitute surgical treatment of nails; Surgical treatment of asymptomatic conditions 1