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 hematoma14;

  * Severe or recurrent fungal nail infection that has failed to respond to usual, less invasive treatment (e.g., pharmacological treatment, debridement);

  * Onychogryphosis or onychauxis1;

  * Congenital or acquired nail dystrophies that jeopardize the integrity of the finger or toe1,8;

  * Diagnosis of suspected lichen planus or psoriasis of the fingernail or toenail1;

  * Subungual and periungual tumors5

  * 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 nail1,13;

  * 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 conditions1

Abdullah and Abbas published a clinical literature review presenting common
nail alterations and disorders that occur in the elderly population and their
management options.1 The elderly are at an increased risk of nail alterations,
including normal age-related changes and nail disorders that are more common
in this specific population. Secondary factors that may contribute to
pathologic nail changes include impaired circulation at the distal
extremities, faulty biomechanics, infections, neoplasms, and skin or systemic
diseases with nail manifestations. These factors can affect the nail plate or
involve other components of the nail unit (e.g., matrix, nail bed,
hyponychium, or nail folds). These nail changes can impair the daily
activities of this older population whose activities might already be
restricted. Common nail disorders in this population include onychauxis,
onychocryptosis, infections (e.g., onychomycosis), subungual hematoma, and
malignancies of the nail apparatus.

Tos et al. published a review article, which addressed the surgical treatment
of acute fingernail injuries.14 This review focused on several nailbed and
fingertip injuries. One such injury reviewed was that of a subungual hematoma.
The authors suggested that when >50% involvement of the nail plate is
associated with a fracture of the distal phalanx, examination of the nail bed
is recommended. The fingernail should be detached, the hematoma drained, and
the nail lesions should be identified and eventually treated.

Multiple publications (Eekhof et al; Geizhals et al; Kline; Mayeaux et al;
Vlahovic) describe the ingrown nail (onychocryptosis) and potential approaches
to treatment.6,7,10,13,15 Eekhof et al. updated the Cochrane review 'Surgical
treatments for ingrowing toenails' in order to evaluate the effects of non-
surgical and surgical interventions in a medical setting for ingrowing
toenails.6 Two authors independently selected studies that included randomized
control trials (RCT) of non-surgical and surgical interventions for ingrowing
toenails, assessed methodological quality, and extracted data from the
selected studies. The group then analyzed outcomes as risk ratios (RR) with
95% confidence intervals (CI). This update included 24 RCT studies, with a
total of 2,826 participants, 7 of the studies were included in a previous
review. Five studies were on non-surgical interventions, and 19 were on
surgical interventions. The goal of surgical treatment is to remove the
interaction between the nail plate and the nail fold to eliminate the local
trauma and inflammatory reaction. These approaches are superior to non-
surgical ones for preventing recurrence. In the Cochrane review, 1 study
demonstrated no significant difference in recurrence with nail-edge excision
and total avulsion of the nail. Less recurrence was noted after 12 months
with wedge resection (RR = 0.19; 95% CI, 0.05 to 0.80) and radical excision of
the nail fold (RR = 0.17; 95% CI, 0.04 to 0.72) than with the rotational flap
technique of the nail fold. Prevention of recurrence between wedge resection
and radical excision of the nail fold showed no significant difference after
12 months.

The most common, and preferred, surgical approach is partial avulsion of the
lateral edge of the nail plate (Collins et al.)3 often followed by lateral
horn matrixectomy by phenolization or surgical excision of the lateral horn of
the nail matrix. Both approaches appear equally effective. The recurrence
rate, for ingrown toenail, with a simple partial nail avulsion is
approximately 70%.15 A Cochrane systematic review6 found that partial nail
avulsion combined with phenolization is more effective at preventing
symptomatic recurrence than surgical excision without phenolization (1 in 25
patients vs. 8 in 21 patients respectively). Electrosurgical or laser ablation
of the matrix are also successful alternatives.

Kouba et al. published evidence-based clinical recommendations to address the
clinical use and safety of local anesthesia for dermatologic office-based
procedures.11 Two hundred one studies were collated, each study was reviewed
and ranked based on relevance and the level of evidence for specific clinical
questions. Evidence tables were generated for these studies and used by the
authors in developing clinical recommendations. This review supports the
recommendations for the use of topical anesthesia for office-based procedures.
Local infiltrative anesthesia is safe and recommended for office-based
dermatologic procedures including, but not limited to, obtaining a biopsy
specimen, excision, wound closure, tissue rearrangement, skin grafting,
cauterization, nonablative laser, and ablative skin resurfacing. Also, nerve
blocks should be considered as an alternative or, in addition to, infiltrative
anesthesia for procedures on the face, hands, feet, and digits.

A study conducted by Yaemsiri et al. was performed to estimate the average
growth rate of fingernails and toenails.16 Prior to this study, the authors
explain that only a few observational studies had been conducted, all prior to
1980. Twenty-two healthy American young adults marked their nails close to the
proximal nail fold following a standardized protocol and recorded the date and
the distance from the proximal nail fold to the mark. Participants recorded
the date and distance from the proximal nail fold to the mark again in 1-3
months. Nail growth rate was calculated based on recorded distance and time
between the 2 measurements. The authors found that the average fingernail
growth rate was faster than that of toenails (3.47 vs. 1.62 mmmonth, P <
0.01). Younger age, male gender, and onychophagia were associated with faster
nail growth rate; however, the differences were not statistically significant.

According to the literature review by Abdullah et al., with advancing age,
normal characteristic changes in the growth rate and morphology of the nail
plate occur.1 Although not completely understood, the underlying mechanisms
for these changes might be related to dysfunctional blood circulation at the
distal extremities or to the effects of ultraviolet radiation. Tos et al.
notes that an injured nail will be pushed off by the new nail and reach
complete growth at 4-6 months after trauma.14 Nail plate growth rates of
fingernails and toenails normally average 3.0 and 1.0 mm/month, respectively.
As patients age, starting at the age of 25 years, this rate tends to decrease
by approximately 0.5% per year.1

Published peer-reviewed literature has shown that surgical treatment of nails
is recommended in moderate to severe onychocryptosis, subungual
abscess/hematoma, complicated injury of the toes or fingers involving the nail
component, severe or recurrent fungal nail infection that has failed less
invasive treatment, onychogryphosis, onychauxis, congenital or acquired nail
dystrophies that jeopardize the integrity of the finger or toe, diagnosis of
suspected lichen planus or psoriasis of the fingernail or toenail, and
treatment of subungual or periungual tumors. Surgical treatment of nails
should be considered, especially in circumstances where more conservative
measures of treatment have failed.

In addition, when consideration is being given for a repeat nail avulsion on
the same toe or finger, studies show that complete regrowth of an avulsed
toenail may require up to 8-12 months, while an avulsed fingernail usually
requires 4-6 months. This data assists in supporting the utilization
parameters outlined in this LCD.