Ingrown toenail surgery

Ingrown toenail surgery is a podiatric procedure that involves removing part or all of the toenail to treat infection or pain from an ingrown nail. Insurance companies such as Blue Cross Blue Shield, Aetna, and Cigna often cover medically necessary ingrown toenail surgeries when conservative treatments (e.g. antibiotics, soaks) fail.

Most health insurance policies require pre-authorization for surgical excision but typically exclude cosmetic removal. Patients usually face copays or coinsurance, with average out-of-pocket costs for insured individuals ranging from $30 to $150 per procedure, based on 2023 data from Healthcare Bluebook.

Surgeons usually bill CPT codes 11730 (partial nail removal) or 11750 (complete nail removal), which directly impact reimbursement rates. Insurance providers categorize repeated procedures as separate claims if medical necessity persists due to recurrence documented by clinical notes.

Medically necessary examples include severe pain with drainage, recurrent infections confirmed by labs, or significant difficulty walking verified by a physician. Private insurances like UnitedHealthcare may request supporting documents such as photographs or progress notes for claim approval.

Medicaid covers ingrown toenail surgery when documentation shows failure of non-surgical management and functional impairment, as stated in state guidelines including California’s Medi-Cal manual, as stated by YourInsurance.info. Medicare Part B covers the procedure if the patient’s physician certifies symptoms interfere with ambulation, referencing CMS policy 100-02 Chapter 15 Section 290(B)(4).

Short-term disability insurance and FMLA generally apply only if recovery prevents work for longer than three days and a doctor attests in writing to incapacity. Reimbursement denial most frequently occurs for lack of medical records, procedural coding errors, or absence of trialed conservative care reported in appeal decisions collected by the American Podiatric Medical Association in 2022.