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August 11, 2014

Recent Denials for Nail Debridement

CGS identified an issue that affected claims for nail debridement (CPT codes 11720 and 11721) that resulted claims being denied in error. These claims were submitted with ICD-9 codes that are considered to meet coverage requirements per our Local Coverage Determination (L31896, "Routine Foot Care and Debridement of Nails"). Affected claims were submitted from July 11-31, 2014.

CGS has made a correction to our claims processing system, and claims submitted after July 31 are being processed correctly. CGS will automatically reprocess claims that were denied in error; it is not necessary to submit redetermination requests or reopening requests for these services.

Because CGS will reprocess all claims for these CPT codes submitted by Kentucky providers between the affected dates, it is possible that you will receive another, correct denial. If this is the case and you disagree with the denial, you may submit a Redetermination Request at that time, within 120 days of the initial determination, and include supporting documentation.

  • Registered users may submit Redetermination Requests electronically and securely using the myCGS Web portal.
  • All providers may submit written Redetermination Requests; CGS strongly encourages you to use the Redetermination Request formPDF for any written appeals).
  • Before you appeal: please note that claims for CPT codes 11720 and 11721 require a primary diagnosis and a secondary diagnosis in order to be covered, and the patient's medical record must contain documentation to support the medical necessity of all services submitted to Medicare.

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