Non-Powered Negative Pressure Wound Therapy System

Section: Durable Medical Equipment
Effective Date: July 01, 2018
Revised Date: August 02, 2019
Last Reviewed: July 16, 2019

Description

The purpose of the non-powered negative pressure wound therapy system (NPWT) is to promote wound healing. The non-powered NPWT system is a portable negative pressure wound therapy device indicated for individuals who would benefit from a suction device particularly as the device may promote wound healing. It is also indicated for removal of small amounts of exudate from chronic, acute, traumatic, subacute and dehisced wounds, partial-thickness burns, ulcers (e.g., diabetic or pressure), and surgically closed incisions and flaps. 

Criteria

A non-powered negative pressure wound therapy system (e.g., Smart Negative Pressure [SNaP] Wound Care System, PICO) and related supplies may be considered medically necessary for the following conditions: 

  • The individual has a chronic (i.e., being present for at least 30 days) Stage III or IV pressure ulcer, diabetic ulcer of the lower extremity or venous ulcer of the lower extremity. 
  • An ulcer therapy program as described below, as applicable to the type of ulcer, should have been tried or considered and ruled out prior to application of non-powered NPWT. 
    • For all ulcers, the ulcer therapy program must include a minimum of all of the following general measures which should either be addressed, applied, or considered and ruled out prior to application of non-powered NPWT: 
      • Documentation in the individual's medical record of evaluation, care and ulcer measurements by a licensed medical professional; and
      • Application of dressings to maintain a moist environment; and
      • Debridement of necrotic tissue if present; and
      • Evaluation of and provision for adequate nutritional status. 
    • For Stage III or IV pressure ulcers: 
      • The individual has been appropriately turned and positioned; and
      • The individual has used an appropriate support surface for pressure ulcers on the posterior trunk or pelvis; and
      • The individual's moisture and incontinence have been appropriately managed. 
    • For diabetic ulcers: 
      • The individual has been on a comprehensive diabetic management program; and
      • Reduction in pressure on a foot ulcer has been accomplished with appropriate modalities. 
    • For venous insufficiency ulcers: 
      • Compression bandages and/or garments have been consistently applied; and
      • Leg elevation and ambulation have been encouraged. 

A non-powered NPWT system will be denied as not medically necessary when submitted for the treatment of surgical (e.g., dehiscence), traumatic, and other types of wounds. 

Once placed on a non-powered NPWT system and supplies, in order for coverage to continue, a licensed medical professional must, on a regular basis: 

  • Directly assess the ulcer(s) being treated with the non-powered NPWT system; and
  • At least monthly, document changes in the ulcer's dimensions and characteristics. 

The health care professional must also record ulcer measurements consistently and regularly in the individual's records. This documentation is necessary to establish the medical necessity of the device for the individual and must continue in order for coverage to continue for an eligible non-powered NPWT system. 

A licensed health care professional, for the purposes of this policy, may be a physician, physician's assistant (PA), registered nurse (RN), licensed practical nurse (LPN), or physical therapist (PT). The practitioner should be licensed to assess ulcers and/or administer ulcer care within the state where the member is receiving non-powered NPWT. 

Procedure Codes

97607      97608  

A non-powered NPWT system used in the treatment of children from birth up to and including 12 years of age is considered experimental/investigational and, therefore, non-covered.According to the U.S. Food and Drug Administration (FDA), the safety and effectiveness of NPWT systems in newborns, infants and children has not been established. 

Procedure Codes

97607      97608  

A non-powered NPWT system and supplies will be denied at any time as not medically necessary, if ONE OR MORE of the following are present: 

  • Actively infected ulcers; or
  • Inadequately drained ulcers; or
  • Inadequately debrided ulcers; or
  • Exposed blood vessels, anastomotic sites, organs, tendons, or nerves; or
  • Ulcer containing malignancy; or
  • Fistulas; or
  • Untreated osteomyelitis within the vicinity of the ulcer; or
  • Actively bleeding ulcers. 

The non-powered NPWT system and supplies will be denied as not medically necessary with ANY of the following, whichever occurs first: 

  • Adequate ulcer healing has occurred to the degree that non-powered NPWT may be discontinued, in the judgment of the treating physician; or
  • Any measurable degree of ulcer healing has failed to occur over the prior month as documented in the individual's records; or
  • Four months (including the time non-powered NPWT was applied in an inpatient setting prior to discharge to the home) have elapsed using a non-powered NPWT device in the treatment of any ulcer. 

Coverage beyond 4 months will be given individual consideration based upon additional documentation. 

This additional documentation must address the initial condition of the ulcer including measurements, efforts to address all aspects of ulcer care, subsequent monthly ulcer measurements, and what changes in ulcer therapy are being applied to effect ulcer healing. This information must be updated with each subsequent request for additional months of use of non-powered NPWT. 

Procedure Codes

97607      97608   A9272

Supplies

Supplies for non-powered NPWT are limited to the following. Requests for amounts greater than the stated limits will be denied as not medically necessary. 

  • Cartridge - 10 cartridges per ulcer per month Additional cartridges per month must be supported by documentation evidencing the volume of drainage of exudates. 
  • Dressings - 10 dressings per ulcer per month Additional dressings per month must be supported by documentation in the individual'smedical record, and must be available upon request. 

Currently, the available non-powered NPWT dressing is 15x15cm in size.Allowing for the suggested 1cm overlap on each border to create a good seal, 13x13cm is currently the maximum diameter for the ulcer being treated with this system. 

Only 1 strap per episode of treatment may be considered medically necessary. 

Procedure Codes

A9272

Staging of Pressure Ulcers

The following description of staging of pressure ulcers should be used when reviewing use of the NPWT device in the treatment of ulcers: 

Stage I: Observable pressure related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel), and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. 

Stage II: Partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. 

Stage III: Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. 

Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers.

Diagnosis Codes

Covered Diagnosis Codes For procedure codes 97607, 97608, and A9272

E08.51  E08.52  E08.59  E08.610  E08.618  E08.621  E08.622 
E08.628  E08.630  E08.638  E08.69  E08.8  E08.9  E09.39 
E09.40  E09.41  E09.42  E09.43  E09.44  E09.49  E09.51 
E09.52  E09.59  E09.610  E09.618  E09.620  E09.621  E09.622 
E09.628  E09.630  E09.638  E09.69  E10.21  E10.40  E10.41 
E10.42  E10.43  E10.44  E10.49  E10.51  E10.52  E10.59 
E10.610  E10.618  E10.620  E10.621  E10.622  E10.628  E10.630 
E10.638  E10.65  E10.69  E10.8  E10.9  E11.21  E11.39 
E11.40  E11.41  E11.42  E11.43  E11.44  E11.49  E11.51 
E11.52  E11.59  E11.610  E11.618  E11.620  E11.621  E11.622 
E11.628  E11.630  E11.638  E11.69  E11.8  E11.9  E13.21 
E13.39  E13.40  E13.41  E13.42  E13.43  E13.44  E13.49 
E13.51  E13.52  E13.59  E13.610  E13.618  E13.620  E13.621 
E13.622  E13.628  E13.630  E13.638  E13.69  E13.8  E13.9 
I70.231  I70.231  I70.232  I70.233  I70.233  I70.234  I70.234 
I70.235  I70.235  I70.238  I70.238  I70.239  I70.239  I70.241 
I70.241  I70.242  I70.243  I70.243  I70.244  I70.244  I70.245 
I70.245  I70.248  I70.248  I70.249  I70.249  I70.331  I70.331 
I70.332  I70.333  I70.333  I70.334  I70.334  I70.335  I70.335 
I70.338  I70.338  I70.339  I70.339  I70.341  I70.341  I70.342 
I70.343  I70.343  I70.344  I70.344  I70.345  I70.345  I70.348 
I70.348  I70.349  I70.349  I70.431  I70.431  I70.432  I70.433 
I70.433  I70.434  I70.434  I70.435  I70.435  I70.438  I70.438 
I70.439  I70.439  I70.441  I70.441  I70.442  I70.443  I70.443 
I70.444  I70.444  I70.445  I70.445  I70.448  I70.448  I70.449 
I70.449  I70.531  I70.531  I70.532  I70.533  I70.533  I70.534 
I70.534  I70.535  I70.535  I70.538  I70.538  I70.539  I70.539 
I70.541  I70.541  I70.542  I70.543  I70.543  I70.544  I70.544 
I70.545  I70.545  I70.548  I70.548  I70.549  I70.549  I70.631 
I70.631  I70.632  I70.633  I70.633  I70.634  I70.634  I70.635 
I70.635  I70.638  I70.638  I70.639  I70.639  I70.641  I70.641 
I70.642  I70.643  I70.643  I70.644  I70.644  I70.645  I70.645 
I70.648  I70.648  I70.649  I70.649  I70.731  I70.731  I70.732 
I70.733  I70.733  I70.734  I70.734  I70.735  I70.735  I70.738 
I70.738  I70.739  I70.739  I70.741  I70.741  I70.742  I70.743 
I70.743  I70.744  I70.744  I70.745  I70.745  I70.748  I70.748 
I70.749  I70.749  I83.001  I83.002  I83.003  I83.004  I83.005 
I83.008  I83.009  I83.011  I83.012  I83.013  I83.014  I83.015 
I83.018  I83.019  I83.021  I83.022  I83.023  I83.024  I83.025 
I83.028  I83.029  I83.201  I83.202  I83.203  I83.204  I83.205 
I83.208  I83.209  I83.211  I83.212  I83.213  I83.214  I83.215 
I83.218  I83.219  I83.221  I83.222  I83.223  I83.224  I83.225 
I83.228  I83.229  I87.011  I87.012  I87.013  I87.019  I87.031 
I87.032  I87.033  I87.039  I87.2  I87.2  I87.311  I87.311 
I87.312  I87.312  I87.313  I87.313  I87.319  I87.9  I87.9 
L89.003  L89.004  L89.013  L89.014  L89.023  L89.024  L89.103 
L89.104  L89.113  L89.114  L89.123  L89.124  L89.133  L89.134 
L89.143  L89.144  L89.153  L89.154  L89.203  L89.204  L89.213 
L89.214  L89.223  L89.224  L89.303  L89.313  L89.314  L89.323 
L89.324  L89.43  L89.44  L89.503  L89.504  L89.513  L89.514 
L89.523  L89.524  L89.603  L89.604  L89.613  L89.614  L89.623 
L89.624  L89.813  L89.814  L89.893  L89.894  L89.93  L89.94 
L97.101  L97.101  L97.102  L97.102  L97.103  L97.103  L97.104 
L97.104  L97.109  L97.109  L97.111  L97.111  L97.112  L97.112 
L97.113  L97.113  L97.114  L97.114  L97.119  L97.119  L97.121 
L97.121  L97.122  L97.122  L97.123  L97.123  L97.124  L97.124 
L97.129  L97.129  L97.201  L97.202  L97.203  L97.204  L97.209 
L97.211  L97.212  L97.213  L97.214  L97.219  L97.221  L97.222 
L97.223  L97.224  L97.229  L97.301  L97.301  L97.302  L97.302 
L97.303  L97.303  L97.304  L97.304  L97.309  L97.309  L97.311 
L97.311  L97.312  L97.312  L97.313  L97.313  L97.314  L97.314 
L97.319  L97.319  L97.321  L97.321  L97.322  L97.322  L97.323 
L97.323  L97.324  L97.324  L97.329  L97.329  L97.401  L97.401 
L97.402  L97.402  L97.403  L97.403  L97.404  L97.404  L97.409 
L97.409  L97.411  L97.411  L97.412  L97.412  L97.413  L97.413 
L97.414  L97.414  L97.419  L97.419  L97.421  L97.421  L97.422 
L97.422  L97.423  L97.423  L97.424  L97.424  L97.429  L97.429 
L97.501  L97.501  L97.502  L97.502  L97.503  L97.503  L97.504 
L97.504  L97.509  L97.509  L97.511  L97.511  L97.512  L97.512 
L97.513  L97.513  L97.514  L97.514  L97.519  L97.519  L97.521 
L97.521  L97.522  L97.522  L97.523  L97.523  L97.524  L97.524 
L97.529  L97.529  L97.801  L97.801  L97.802  L97.802  L97.803 
L97.803  L97.804  L97.804  L97.809  L97.809  L97.811  L97.811 
L97.812  L97.812  L97.813  L97.813  L97.814  L97.814  L97.819 
L97.819  L97.821  L97.821  L97.822  L97.822  L97.823  L97.823 
L97.824  L97.824  L97.829  L97.829  L97.901  L97.901  L97.902 
L97.902  L97.903  L97.903  L97.904  L97.904  L97.909  L97.909 
L97.911  L97.911  L97.912  L97.912  L97.913  L97.913  L97.914 
L97.914  L97.919  L97.919  L97.921  L97.921  L97.922  L97.922 
L97.923  L97.923  L97.924  L97.924  L97.929  L97.929 

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