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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
The rules say the Medicare program generally does not cover routine foot care. However, this determination 
outlines the specific conditions for which coverage may be allowed under National Medicare regulations. 
The following services are considered to be components of routine foot care, regardless of the provider 
rendering the service: While the Medicare program generally excludes routine foot care services from 
coverage, there are specific indications or exceptions under which there are program benefits. 
Medicare payment may be made for routine foot care when the patient has a systemic disease, such as 
metabolic, neurologic, or peripheral vascular disease, of sufficient severity that performance of such services 
by a nonprofessional person would put the patient at risk (for example, a systemic condition that has resulted in 
severe circulatory embarrassment or areas of desensitization in the patients legs or feet). 
The treatment of warts (including plantar warts) on the foot is covered to the same extent as services provided 
for the treatment of warts located elsewhere on the body. Services ordinarily considered routine might also be 
covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis 
and treatment of diabetic ulcers, wounds, and infections. Treatment of mycotic nails may be covered under the 
exceptions to the routine foot care exclusion. The class findings, outlined below, or the presence of qualifying 
systemic illnesses causing a peripheral neuropathy, must be present. Payment may be made for the debridement 
of a mycotic nail (whether by manual method or by electrical grinder) when definitive antifungal treatment 
options have been reviewed and discussed with the patient at the initial visit and the physician attending the 
mycotic condition documents that the following criteria are met: In the case of ambulatory patients there exists: 
Clinical evidence of mycosis of the toenail, and marked limitation of ambulation, pain, or secondary infection 
resulting from the thickening and dystrophy of the infected toenail plate. In the case of non-ambulatory patients 
there exists: Clinical evidence of mycosis of the toenail, and the patient suffers from pain or secondary 
infection resulting from the thickening and dystrophy of the infected toenail plate. 
  Absent posterior tibial pulse; 
 Advanced trophic changes as: 
 hair growth (decrease or increase) nail changes (thickening) pigmentary changes (discoloration) skin texture 
(thin, shiny) skin color (rubor or redness); and 
 Absent dorsalis pedis pulse. 
 Claudication, 
 Temperature changes (e.g., cold feet); 
 Edema; 
 Paresthesias (abnormal spontaneous sensations in the feet); and 
 Burning. 
In the absence of a systemic condition, the following criteria must be met: In addition, procedures for treating 
toenails are covered for the following: Onychogryphosis (defined as long-standing thickening, in which 
typically a curved hooked nail [ram's horn nail] occurs), and there is marked limitation of ambulation, pain, 
and/or secondary infection where the nail plate is causing symptomatic indentation of or minor laceration of the 
affected distal toe; and/or Onychauxis (defined as a thickening [hypertrophy] of the base of the nail/nail bed) 
and there is marked limitation of ambulation, pain, and/or secondary infection that causes symptoms. 
You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage Determination (LCD) 
L33636, Routine Foot Care and Debridement of Nails. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract also says that the Plan covers Podiatry services: Routine foot care for members with certain medical 
conditions affecting the lower limbs. You can find this information on page 85 of the Plan's 2022 Evidence of 
Coverage.