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Ask The Insurance Decoder

Lynne Lucio

By Lynne Lucio

Q.  Recently my podiatrist removed an ingrown toenail from my big toe.  He submitted the claim to my insurance company but they have denied it, saying that the procedure is not covered.  Can you explain this to me please?—William F., La Jolla, CA

A.  This is a good question and one I hear pretty often.  Your toe hurts and although you’ve tried to handle it yourself, it still hurts.  Finally, going to the doctor seems like the reasonable and prudent thing to do.  But, health plan designs can be tricky.  Some plans will pay for this type of procedure if the patient is a diabetic.  This is due to the nature of diabetes and its affect on feet and lower extremities.  Diabetic patients have to be very careful to avoid letting any kind of injury or wound to feet and legs become infected or worse, septic.  When plans allow ingrown toenail removal for diabetics, there has to be a diabetic diagnosis code noted on the claim so that the insurance company knows that the patient is a diabetic.  Many plans only allow coverage of the removal of ingrown toenails when all or part of the nail root is removed.  Plans that have this provision in them want to ensure that the problem is fixed for good, rather than having the patient incur regular doctor charges to continue to remove an ingrown nail, over and over again.  If you’re not a diabetic, it may be a good idea to have regular pedicures so the nail technician can prevent future ingrown toenail problems from cropping up in the first place.

ASK The Insurance Decoder © Copyright 2012, Lynne Lucio.  All rights reserved.

Lynne Lucio, the author of The Insurance Decoder:  How to Maximize Your Health Insurance Benefits, Minimize Out-Of-Pocket Expenses and Stay One step Ahead of Your Insurance Company, has been a health insurance professional for over 20 years.  As an insurance insider, Lynne learned how to decipher the medical claims labyrinth and developed the specific and practical knowledge of the claims process.  Throughout her career, Lynne has shared her expertise with thousands of insured consumers, helping them resolve complicated health claims while showing them how to take full advantage of their health insurance benefits.  The depth and breadth of Lynne’s knowledge of the topic encompasses not only the claims process but also the laws that influence and regulate health coverage, including ERISA, COBRA, FMLA, USERRA, HIPAA and others.  Lynne provides consulting services to covered individuals and writes about health insurance issues on (www.ezine.com).  For more information, or to submit your own health insurance related questions, contact Lynne at theinsurancedecoder@gmail.com.  Your question may be answered in a future column. 

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