Medical Policy

Effective Date:11/13/2003	Title:Polydactyly (Excessive Toes or Fingers)
Revision Date:10/01/2015	Document:BI008:00
CPT Code(s):11200, 11201, 26587, 28344
Public Statement
*Effective Date:* a) This policy will apply to all services performed on or after the above Revision date which will become the new effective date. b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. The removal of excess or accessory toes and fingers is a covered service.
Medical Statement
Removal of excess digits is covered. When the excess digits contain bone, cartilage, or nail, the code for their removal is 26587 (finger) or 28344 (toe). When the excess digit contains only skin and subcutaneous tissue, the correct code for removal is 11200. For further discussion of code 11200, see the policy on Skin Tags Removal – BI004. Codes Used In This BI: 11200 Removal of skin tags 11201 Removal skin tags add-on 26587 Reconstruct extra finger 28344 Reconstruct toe
Limits
Intentially left empty
Reference
Intentially left empty
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.