Criteria
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date; or
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.
NPWT pumps/Vacuum Assisted Closure (VAC) for nonhealing wounds may be considered medically necessary when
ANY
of the following conditions are met:
Ulcers and Wounds in the Outpatient Setting
-
Chronic, nonhealing stage III or IV pressure ulcer, neuropathic (e.g., diabetic) ulcer, venous or arterial insufficiency ulcer, or chronic ulcer of mixed etiology (i.e., present for at least 30 days);
and
-
Wound therapy program, as described below, (applicable to the type of wound) have been tried or considered and ruled out prior to application of NPWT pumps/VAC.
-
Documentation in the individual's medical record of evaluation, care and wound measurements by a licensed medical professional (i.e., physician, PA, CRNP, RN, LPN, RPT);
and
-
Application of dressings to maintain a moist wound environment;
and
-
Debridement of necrotic tissue if present;
and
-
Evaluation of and provision for adequate nutritional status;
or
-
The individual has been on an appropriately turned and positioned schedule;
and
-
The individual has used a support surface for pressure ulcers on the trunk or pelvis;
and
-
The individual's moisture and incontinence have been appropriately managed;
or
-
All ulcers or wound types (i.e., surgically created, traumatic), must include
ALL
of the following therapeutic measures addressed, applied, or considered and ruled out prior to application of NPWT pumps/VAC:
- Chronic stage III or IV pressure ulcers:
-
Neuropathic (e.g., diabetic, ulcers)
-
The individual has been on a comprehensive diabetic management program;
and
-
Reduction in pressure on a foot ulcer has accomplished with appropriate modalities (i.e., saline wet-to-dry dressings; debridement etc.);
and
-
Appropriate foot care (i., visual inspection, appropriate footwear, etc.);
or
- Venous or arterial insufficiency ulcers:
-
Compression bandages and/or garments have been consistently applied;
and
-
Leg elevation and ambulation have been encouraged;
or
- Surgically created wound or traumatic wound:
-
The wound requires accelerated formation of granulation tissue that cannot be achieved by other available topical wound treatments (e.g., comorbidities that prevent healing);
and
- Results of previous wound treatments are documented.
Ulcers and Wounds Encountered in an Inpatient Setting
- NPWT pumps/VAC may be considered medically necessary when continuation of treatment is ordered beyond discharge to the home setting.
- An ulcer or wound is encountered in the inpatient setting and after wound treatments have been tried or considered and ruled out, NPWT pumps/VAC is initiated because it is considered, in the judgment of the treating physician, the best available treatment option.
- Complications of a surgically created wound (e.g., dehiscence, post-sternotomy disunion with exposed sternal bone, etc.) or traumatic wound, (e.g., preoperative flap or graft, exposed bones), where there is documentation of the medical necessity for accelerated formation of granulation tissue which cannot be achieved by other available topical wound treatments (e.g., other conditions that will not allow for healing times achievable with other topical wound treatments).
If the above criteria are not met for the use of NPWT pumps/VAC systems in either setting, the pump and supplies are considered not medically necessary.
NPWT pumps/VAC systems and their supplies used in the treatment of children from birth up to and including 12 years of age are considered experimental/investigational and, therefore, non-covered, because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
All other uses of NPWT pumps/VAC systems for the treatment of chronic wounds are considered not medically necessary.
Procedure Codes
| 97605 | 97606 | A6550 | A7000 | E2402 |
