LCD/NCD Portal

NCD70.2.1

 

SERVICES PROVIDED FOR THE DIAGNOSIS AND TREATMENT OF DIABETIC SENSORY NEUROPATHY WITH LOSS OF PROTECTIVE SENSATION (AKA DIABETIC PERIPHERAL NEUROPATHY)

 

Effective Date of this Version

7/1/2002

 

Benefit Category

• Physicians' Services

• Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

 

Item/Service Description

• Presently, peripheral neuropathy, or diabetic sensory neuropathy, is the most common factor leading to amputation in people with diabetes.

• In diabetes, sensory neuropathy is an anatomically diffuse process primarily affecting sensory and autonomic fibers; however, distal motor findings may be present in advanced cases.

• Long nerves are affected first, with symptoms typically beginning insidiously in the toes and then advancing proximally.

• This leads to loss of protective sensation (LOPS), whereby a person is unable to feel minor trauma from mechanical, thermal, or chemical sources.

• When foot lesions are present, the reduction in autonomic nerve functions may also inhibit wound healing.

 

Indications and Limitations of Coverage

• Diabetic sensory neuropathy with LOPS is a localized illness of the feet and falls within the regulation's exception to the general exclusionary rule (see 42 CFR §411.15(l)(1)(i)).

o Foot exams for people with diabetic sensory neuropathy with LOPS are reasonable and necessary to allow for early intervention in serious complications that typically afflict diabetics with the disease.

• Effective for services furnished on or after July 1, 2002, Medicare covers, as a physician service, an evaluation (examination and treatment) of the feet no more often than every six months for individuals with a documented diagnosis of diabetic sensory neuropathy and LOPS, as long as the beneficiary has not seen a foot care specialist for some other reason in the interim.

o LOPS shall be diagnosed through sensory testing with the 5.07 monofilament using established guidelines, such as those developed by the National Institute of Diabetes and Digestive and Kidney Diseases guidelines.

o Five sites should be tested on the plantar surface of each foot, according to the National Institute of Diabetes and Digestive and Kidney Diseases guidelines.

o 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.

o Heavily callused areas should be avoided.

o 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.

o The examination includes:

 A patient history.

 A physical examination that must consist of at least the following elements:

 Visual inspection of forefoot and hindfoot (including toe web spaces).

 Evaluation of protective sensation.

 Evaluation of foot structure and biomechanics.

 Evaluation of vascular status and skin integrity.

 Evaluation of the need for special footwear.

 Patient education.

o Treatment includes, but is not limited to:

 Local care of superficial wounds.

 Debridement of corns and calluses.

 Trimming and debridement of nails.

• The diagnosis of diabetic sensory neuropathy with LOPS should be established and documented prior to coverage of foot care.

o Other causes of peripheral neuropathy should be considered and investigated by the primary care physician prior to initiating or referring for foot care for persons with LOPS.

Claims Processing Instructions

• TN AB-02-158 (Program Memorandum Intermediaries/Carriers)

• TN AB-02-096 (Program Memorandum Intermediaries/Carriers)

• TN AB-02-109 (Program Memorandum Intermediaries/Carriers)

• TN A-02-039 (Program Memorandum Intermediaries)

• TN AB-02-042 (Program Memorandum Intermediaries/Carriers)

• TN 498 (Medicare Claims Processing Manual)

 

Coverage Transmittal Link

http://www.cms.gov/transmittals/downloads/R153CIM.pdf

 

Medicare NCD Link