Coverage Indications, Limitations, and/or Medical Necessity

    This LCD describes conditions under which the coverage of nail avulsion/excision may be considered.

    An ingrown nail is growth of the nail edge into the surrounding soft tissue that may result in pain, inflammation or infection. This condition most commonly occurs in the great toes and may require surgical management. Other conditions may also require avulsion of part or all of a nail.

    The surgical treatment of ingrown nails is considered to be medically appropriate and reasonable for an ingrown toenail in the advanced stage in which the lateral nail fold bulges over the nail plate causing erythema, edema, and tenderness, and granulation of the epithelium inhibits serous drainage and precludes any chance of elevating the nail edge from the dermis of the lateral skin fold.

    Treatment of simple uncomplicated or asymptomatic ingrown nail such as removal of a nail spicule may be considered to be routine foot care as are other trimming, cutting, clipping and debriding of a nail distal to the eponychium. Routine foot care is covered only when certain systemic conditions are present. (Refer to LCD: Routine Foot Care).

    The following surgical procedures represent the options used to treat a complicated/symptomatic ingrown nail(s):

    • Avulsion of a nail (CPT codes 11730 and 11732) involving separation and removal of the entire nail plate or a portion of nail plate (including the entire length of the nail border to and under the eponychium). A nail avulsion usually requires injected local anesthesia except in instances wherein the digit is devoid of sensation or there are other extenuating circumstances for which injectable anesthesia is not required or is medically contraindicated.
    • Excision of the nail and the nail matrix (CPT code 11750) performed under local anesthesia (unless the digit is devoid of sensation, which should be documented) requiring separation and removal of the entire nail plate or a portion of nail plate (including the entire length of the nail border to and under the eponychium) followed by destruction or permanent removal of the associated nail matrix.
    • Wedge excision of the nail fold hypertrophic granulation tissue with removal of the offending portion of the nail (CPT code 11765).

    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 another nail avulsion. Therefore, a partial or complete excision of nail and nail matrix may be the preferred course of treatment for recurrent ingrown nails.

    The surgical treatment of nails is also covered for the following indications:

    • Subungal abscess.
    • Contusion injuries of nails.
    • Crushing injuries of the toes.
    • Crushing injuries of the fingers.
    • Paronychia.
    • Complicated wounds of the toes involving nail components.

    • Deformed nails that prevent wearing shoes or otherwise jeopardize the integrity of the toe.

An ingrown nail is growth of the nail edge into the surrounding soft tissue that may result in pain, inflammation or infection. This condition most commonly occurs in the great toes and may require surgical management. Other conditions may also require avulsion of part or all of a nail. This policy describes conditions under which Medicare payment for nail avulsion may be made.

Treatment of simple uncomplicated or asymptomatic ingrowing nail by removal of the offending nail spicule not requiring local anesthesia is considered to be routine foot care as are other trimming, cutting, clipping and debriding of a nail distal to the eponychium. Routine foot care is covered only when certain systemic conditions are present. Payment conditions for routine foot care are described in the TrailBlazer LCD “Routine Foot Care – 4P-11AB.”

The following surgical procedures represent the options used to treat complicated/symptomatic ingrowing nail(s):

  • Avulsion of a nail (CPT codes 11730 and 11732) involving separation and removal of the entire nail plate or a portion of nail plate (including the entire length of the nail border to and under the eponychium). A nail avulsion usually requires injected local anesthesia except in instances wherein the digit is devoid of sensation or there are other extenuating circumstances for which injectable anesthesia is not required or is medically contraindicated.

  • Excision of the nail and the nail matrix (CPT code 11750) performed under local anesthesia requiring separation and removal of the entire nail plate or a portion of nail plate (including the entire length of the nail border to and under the eponychium) followed by destruction or permanent removal of the associated nail matrix.
  • Wedge excision of the nail fold hypertrophic granulation tissue with removal of the offending portion of the nail (CPT procedure code 11765).
Regrowth of the nail usually requires at least four months. With appropriate surgical management and instruction for proper shoes and nail care, the problem of ingrowing nails should not recur.

The surgical treatment of nails is also covered for the following indications:
  • Subungal abscess.
  • Contusion injuries of nails.
  • Crushing injuries of the toes.
  • Crushing injuries of the fingers.
  • Paronychia.
  • Complicated wounds of the toes involving nail components.
  • Deformed nails that prevent wearing shoes or otherwise jeopardize the integrity of the toe.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 21X, 22X, 23X, 71X, 75X, 85X



Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04 Claims Processing Manual for further guidance.
0450, 050X, 051X, 052X, 0761



CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
11730©
Removal of nail plate
11732©
Removal of nail plate, add-on
11750©
Removal of nail bed – Average fee payment $190
11765©
Excision of nail fold, toe

ICD-10 Codes that Support Medical Necessity
     
    Group 1 Codes
    B35.1 Tinea unguium
    I96 Gangrene, not elsewhere classified
    L02.511 Cutaneous abscess of right hand
    L02.512 Cutaneous abscess of left hand
    L02.519 Cutaneous abscess of unspecified hand
    L02.611 Cutaneous abscess of right foot
    L02.612 Cutaneous abscess of left foot
    L02.619 Cutaneous abscess of unspecified foot
    L03.011 Cellulitis of right finger
    L03.012 Cellulitis of left finger
    L03.019 Cellulitis of unspecified finger
    L03.021 Acute lymphangitis of right finger
    L03.022 Acute lymphangitis of left finger
    L03.029 Acute lymphangitis of unspecified finger
    L03.031 Cellulitis of right toe
    L03.032 Cellulitis of left toe
    L03.039 Cellulitis of unspecified toe
    L03.041 Acute lymphangitis of right toe
    L03.042 Acute lymphangitis of left toe
    L03.049 Acute lymphangitis of unspecified toe
    L60.0 Ingrowing nail
    L60.1 Onycholysis
    L60.2 Onychogryphosis
    L60.3 Nail dystrophy
    L60.4 Beau’s lines
    L60.5 Yellow nail syndrome
    L60.8 Other nail disorders
    L60.9 Nail disorder, unspecified
    L92.8 Other granulomatous disorders of the skin and subcutaneous tissue
    L98.0 Pyogenic granuloma
    Q84.3 Anonychia
    Q84.4 Congenital leukonychia
    Q84.5 Enlarged and hypertrophic nails
    Q84.6 Other congenital malformations of nails
    S60.111A Contusion of right thumb with damage to nail, initial encounter
    S60.111D Contusion of right thumb with damage to nail, subsequent encounter
    S60.111S Contusion of right thumb with damage to nail, sequela
    S60.112A Contusion of left thumb with damage to nail, initial encounter
    S60.112D Contusion of left thumb with damage to nail, subsequent encounter
    S60.112S Contusion of left thumb with damage to nail, sequela
    S60.119A Contusion of unspecified thumb with damage to nail, initial encounter
    S60.119D Contusion of unspecified thumb with damage to nail, subsequent encounter
    S60.119S Contusion of unspecified thumb with damage to nail, sequela
    S60.121A Contusion of right index finger with damage to nail, initial encounter
    S60.121D Contusion of right index finger with damage to nail, subsequent encounter
    S60.121S Contusion of right index finger with damage to nail, sequela
    S60.122A Contusion of left index finger with damage to nail, initial encounter
    S60.122D Contusion of left index finger with damage to nail, subsequent encounter
    S60.122S Contusion of left index finger with damage to nail, sequela
    S60.129A Contusion of unspecified index finger with damage to nail, initial encounter
    S60.129D Contusion of unspecified index finger with damage to nail, subsequent encounter
    S60.129S Contusion of unspecified index finger with damage to nail, sequela
    S60.131A Contusion of right middle finger with damage to nail, initial encounter
    S60.131D Contusion of right middle finger with damage to nail, subsequent encounter
    S60.131S Contusion of right middle finger with damage to nail, sequela
    S60.132A Contusion of left middle finger with damage to nail, initial encounter
    S60.132D Contusion of left middle finger with damage to nail, subsequent encounter
    S60.132S Contusion of left middle finger with damage to nail, sequela
    S60.139A Contusion of unspecified middle finger with damage to nail, initial encounter
    S60.139D Contusion of unspecified middle finger with damage to nail, subsequent encounter
    S60.139S Contusion of unspecified middle finger with damage to nail, sequela
    S60.141A Contusion of right ring finger with damage to nail, initial encounter
    S60.141D Contusion of right ring finger with damage to nail, subsequent encounter
    S60.141S Contusion of right ring finger with damage to nail, sequela
    S60.142A Contusion of left ring finger with damage to nail, initial encounter
    S60.142D Contusion of left ring finger with damage to nail, subsequent encounter
    S60.142S Contusion of left ring finger with damage to nail, sequela
    S60.149A Contusion of unspecified ring finger with damage to nail, initial encounter
    S60.149D Contusion of unspecified ring finger with damage to nail, subsequent encounter
    S60.149S Contusion of unspecified ring finger with damage to nail, sequela
    S60.151A Contusion of right little finger with damage to nail, initial encounter
    S60.151D Contusion of right little finger with damage to nail, subsequent encounter
    S60.151S Contusion of right little finger with damage to nail, sequela
    S60.152A Contusion of left little finger with damage to nail, initial encounter
    S60.152D Contusion of left little finger with damage to nail, subsequent encounter
    S60.152S Contusion of left little finger with damage to nail, sequela
    S60.159A Contusion of unspecified little finger with damage to nail, initial encounter
    S60.159D Contusion of unspecified little finger with damage to nail, subsequent encounter
    S60.159S Contusion of unspecified little finger with damage to nail, sequela
    S61.101A Unspecified open wound of right thumb with damage to nail, initial encounter
    S61.101D Unspecified open wound of right thumb with damage to nail, subsequent encounter
    S61.101S Unspecified open wound of right thumb with damage to nail, sequela
    S61.102A Unspecified open wound of left thumb with damage to nail, initial encounter
    S61.102D Unspecified open wound of left thumb with damage to nail, subsequent encounter
    S61.102S Unspecified open wound of left thumb with damage to nail, sequela
    S61.109A Unspecified open wound of unspecified thumb with damage to nail, initial encounter
    S61.109D Unspecified open wound of unspecified thumb with damage to nail, subsequent encounter
    S61.109S Unspecified open wound of unspecified thumb with damage to nail, sequela
    S61.111A Laceration without foreign body of right thumb with damage to nail, initial encounter
    S61.111D Laceration without foreign body of right thumb with damage to nail, subsequent encounter
    S61.111S Laceration without foreign body of right thumb with damage to nail, sequela
    S61.112A Laceration without foreign body of left thumb with damage to nail, initial encounter
    S61.112D Laceration without foreign body of left thumb with damage to nail, subsequent encounter
    S61.112S Laceration without foreign body of left thumb with damage to nail, sequela
    S61.119A Laceration without foreign body of unspecified thumb with damage to nail, initial encounter
    S61.119D Laceration without foreign body of unspecified thumb with damage to nail, subsequent encounter
    S61.119S Laceration without foreign body of unspecified thumb with damage to nail, sequela
    S61.121A Laceration with foreign body of right thumb with damage to nail, initial encounter
    S61.121D Laceration with foreign body of right thumb with damage to nail, subsequent encounter
    S61.121S Laceration with foreign body of right thumb with damage to nail, sequela
    S61.122A Laceration with foreign body of left thumb with damage to nail, initial encounter
    S61.122D Laceration with foreign body of left thumb with damage to nail, subsequent encounter
    S61.122S Laceration with foreign body of left thumb with damage to nail, sequela
    S61.129A Laceration with foreign body of unspecified thumb with damage to nail, initial encounter
    S61.129D Laceration with foreign body of unspecified thumb with damage to nail, subsequent encounter
    S61.129S Laceration with foreign body of unspecified thumb with damage to nail, sequela
    S61.131A Puncture wound without foreign body of right thumb with damage to nail, initial encounter
    S61.131D Puncture wound without foreign body of right thumb with damage to nail, subsequent encounter
    S61.131S Puncture wound without foreign body of right thumb with damage to nail, sequela
    S61.132A Puncture wound without foreign body of left thumb with damage to nail, initial encounter
    S61.132D Puncture wound without foreign body of left thumb with damage to nail, subsequent encounter
    S61.132S Puncture wound without foreign body of left thumb with damage to nail, sequela
    S61.139A Puncture wound without foreign body of unspecified thumb with damage to nail, initial encounter
    S61.139D Puncture wound without foreign body of unspecified thumb with damage to nail, subsequent encounter
    S61.139S Puncture wound without foreign body of unspecified thumb with damage to nail, sequela
    S61.141A Puncture wound with foreign body of right thumb with damage to nail, initial encounter
    S61.141D Puncture wound with foreign body of right thumb with damage to nail, subsequent encounter
    S61.141S Puncture wound with foreign body of right thumb with damage to nail, sequela
    S61.142A Puncture wound with foreign body of left thumb with damage to nail, initial encounter
    S61.142D Puncture wound with foreign body of left thumb with damage to nail, subsequent encounter
    S61.142S Puncture wound with foreign body of left thumb with damage to nail, sequela
    S61.149A Puncture wound with foreign body of unspecified thumb with damage to nail, initial encounter
    S61.149D Puncture wound with foreign body of unspecified thumb with damage to nail, subsequent encounter
    S61.149S Puncture wound with foreign body of unspecified thumb with damage to nail, sequela
    S61.151A Open bite of right thumb with damage to nail, initial encounter
    S61.151D Open bite of right thumb with damage to nail, subsequent encounter
    S61.151S Open bite of right thumb with damage to nail, sequela
    S61.152A Open bite of left thumb with damage to nail, initial encounter
    S61.152D Open bite of left thumb with damage to nail, subsequent encounter
    S61.152S Open bite of left thumb with damage to nail, sequela
    S61.159A Open bite of unspecified thumb with damage to nail, initial encounter
    S61.159D Open bite of unspecified thumb with damage to nail, subsequent encounter
    S61.159S Open bite of unspecified thumb with damage to nail, sequela
    S61.310A Laceration without foreign body of right index finger with damage to nail, initial encounter
    S61.310D Laceration without foreign body of right index finger with damage to nail, subsequent encounter
    S61.310S Laceration without foreign body of right index finger with damage to nail, sequela
    S61.311A Laceration without foreign body of left index finger with damage to nail, initial encounter
    S61.311D Laceration without foreign body of left index finger with damage to nail, subsequent encounter
    S61.311S Laceration without foreign body of left index finger with damage to nail, sequela
    S61.312A Laceration without foreign body of right middle finger with damage to nail, initial encounter
    S61.312D Laceration without foreign body of right middle finger with damage to nail, subsequent encounter
    S61.312S Laceration without foreign body of right middle finger with damage to nail, sequela
    S61.313A Laceration without foreign body of left middle finger with damage to nail, initial encounter
    S61.313D Laceration without foreign body of left middle finger with damage to nail, subsequent encounter
    S61.313S Laceration without foreign body of left middle finger with damage to nail, sequela
    S61.314A Laceration without foreign body of right ring finger with damage to nail, initial encounter
    S61.314D Laceration without foreign body of right ring finger with damage to nail, subsequent encounter
    S61.314S Laceration without foreign body of right ring finger with damage to nail, sequela
    S61.315A Laceration without foreign body of left ring finger with damage to nail, initial encounter
    S61.315D Laceration without foreign body of left ring finger with damage to nail, subsequent encounter
    S61.315S Laceration without foreign body of left ring finger with damage to nail, sequela
    S61.316A Laceration without foreign body of right little finger with damage to nail, initial encounter
    S61.316D Laceration without foreign body of right little finger with damage to nail, subsequent encounter
    S61.316S Laceration without foreign body of right little finger with damage to nail, sequela
    S61.317A Laceration without foreign body of left little finger with damage to nail, initial encounter
    S61.317D Laceration without foreign body of left little finger with damage to nail, subsequent encounter
    S61.317S Laceration without foreign body of left little finger with damage to nail, sequela
    S61.318A Laceration without foreign body of other finger with damage to nail, initial encounter
    S61.318D Laceration without foreign body of other finger with damage to nail, subsequent encounter
    S61.318S Laceration without foreign body of other finger with damage to nail, sequela
    S61.319A Laceration without foreign body of unspecified finger with damage to nail, initial encounter
    S61.319D Laceration without foreign body of unspecified finger with damage to nail, subsequent encounter
    S61.319S Laceration without foreign body of unspecified finger with damage to nail, sequela
    S61.320A Laceration with foreign body of right index finger with damage to nail, initial encounter
    S61.320D Laceration with foreign body of right index finger with damage to nail, subsequent encounter
    S61.320S Laceration with foreign body of right index finger with damage to nail, sequela
    S61.321A Laceration with foreign body of left index finger with damage to nail, initial encounter
    S61.321D Laceration with foreign body of left index finger with damage to nail, subsequent encounter
    S61.321S Laceration with foreign body of left index finger with damage to nail, sequela
    S61.322A Laceration with foreign body of right middle finger with damage to nail, initial encounter
    S61.322D Laceration with foreign body of right middle finger with damage to nail, subsequent encounter
    S61.322S Laceration with foreign body of right middle finger with damage to nail, sequela
    S61.323A Laceration with foreign body of left middle finger with damage to nail, initial encounter
    S61.323D Laceration with foreign body of left middle finger with damage to nail, subsequent encounter
    S61.323S Laceration with foreign body of left middle finger with damage to nail, sequela
    S61.324A Laceration with foreign body of right ring finger with damage to nail, initial encounter
    S61.324D Laceration with foreign body of right ring finger with damage to nail, subsequent encounter
    S61.324S Laceration with foreign body of right ring finger with damage to nail, sequela
    S61.325A Laceration with foreign body of left ring finger with damage to nail, initial encounter
    S61.325D Laceration with foreign body of left ring finger with damage to nail, subsequent encounter
    S61.325S Laceration with foreign body of left ring finger with damage to nail, sequela
    S61.326A Laceration with foreign body of right little finger with damage to nail, initial encounter
    S61.326D Laceration with foreign body of right little finger with damage to nail, subsequent encounter
    S61.326S Laceration with foreign body of right little finger with damage to nail, sequela
    S61.327A Laceration with foreign body of left little finger with damage to nail, initial encounter
    S61.327D Laceration with foreign body of left little finger with damage to nail, subsequent encounter
    S61.327S Laceration with foreign body of left little finger with damage to nail, sequela
    S61.328A Laceration with foreign body of other finger with damage to nail, initial encounter
    S61.328D Laceration with foreign body of other finger with damage to nail, subsequent encounter
    S61.328S Laceration with foreign body of other finger with damage to nail, sequela
    S61.329A Laceration with foreign body of unspecified finger with damage to nail, initial encounter
    S61.329D Laceration with foreign body of unspecified finger with damage to nail, subsequent encounter
    S61.329S Laceration with foreign body of unspecified finger with damage to nail, sequela
    S61.330A Puncture wound without foreign body of right index finger with damage to nail, initial encounter
    S61.330D Puncture wound without foreign body of right index finger with damage to nail, subsequent encounter
    S61.330S Puncture wound without foreign body of right index finger with damage to nail, sequela
    S61.331A Puncture wound without foreign body of left index finger with damage to nail, initial encounter
    S61.331D Puncture wound without foreign body of left index finger with damage to nail, subsequent encounter
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 11730, 11732, 11750 and 11765:



Covered for:
681.00
Cellulitis and abscess of finger, unspecified
681.02
Onychia and paronychia of the finger
681.10–681.11
Cellulitis and abscess of toe
681.9
Cellulitis and abscess of unspecified digit
696.1
Psoriasis, nail
703.0
Ingrowing nail
703.8
Leukonychia, onychauxis, onychogryposis, onycholysis
757.5
Other specified anomalies of nails
883.0–883.2
Open wound of finger(s)
893.0–893.2
Open wound of the toe
923.3
Contusion of fingernail
924.3
Contusion of toe nail
927.3
Crushing injury of finger(s)
928.3
Crushing injury of toe(s)
945.31
Burn of lower limb (including toe and nail unit), third degree
945.41
Burn of lower limb (including toe and nail unit), deep third degree without mention of loss of body part
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses That Support Medical Necessity
N/A
ICD-9-CM Codes That DO NOT Support Medical Necessity
N/A
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.



Documentation Requirements
  • Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
  • If another service is provided along with the avulsion, full documentation of the medical need for the service and description of the procedure must be recorded in the patient’s file.
  • The following information should be included in the patient’s medical record (in the operative note or in progress notes related to a recent/contemporaneous/subsequent E/M encounter):
    • The patient’s primary symptoms and previous treatment (if any) and description of the nail(s) at the time of avulsion services.
    • A complete detailed description of the procedure performed including exact portion of nail removed.
    • Type and quantity of local anesthetic agent used. If injectable anesthesia was not used, the reason must be clearly documented in the patient’s medical record.
    • Post-operative instructions and any follow-up care (such as use of soaks, proper shoes and nail care, to prevent recurrences, antibiotics and follow-up appointments).
Appendices
N/A



Utilization Guidelines

  • Both avulsion and routine trimming/debridement will not be allowed on the same nail on the same day.
  • Medicare will allow ten services per beneficiary per 24 months for CPT codes 11730 and/or 11732. Payment for services beyond this number will require medical review of patient records to determine medical necessity.
  • Medicare payment for CPT codes 11730 and 11732 in places of service other than hospitals or ambulatory surgical centers is limited to 5 services (one of 11730 and 4 of 11732) per day.
Notice: This LCD imposes utilization guideline limitations. Despite Medicare’s allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.