The purpose of the Negative Pressure Wound Therapy (NPWT) device is to promote wound healing. Wound healing is defined as improvement occurring in either surface area or depth of the wound. Lack of improvement of a wound is defined as a lack of progress in quantitative measurements of wound characteristics including wound length and width (surface area), or depth measured serially and documented over a specified time interval.

Negative pressure wound therapy may be considered medically necessary when ALL of the following are met

• A complete wound therapy program involving ALL of the following has been tried or considered and ruled out prior to initiation of NPWT
  • Documentation of evaluation, care, and wound measurements by a licensed medical professional (i.e., physician, PA, CRNP, RN, LPN, RPT)
  • Application of dressings to maintain a moist wound environment
  • Debridement of necrotic tissue if present
  • Evaluation of and provision for adequate nutritional status
• The indication is ONE or more of the following
  • Chronic stage III or IV pressure ulcer and ALL of the following are met
    • The individual has been on an appropriate turn and position schedule
    • The individual’s moisture and incontinence have been appropriately managed
    • A pressure reducing support surface has been used
  • Neuropathic ulcer (e.g., diabetic ulcer) and ALL of the following are met
    • The individual has been on a comprehensive diabetic management program
    • The individual has received reduction in pressure with appropriate modalities (i.e. saline wet-to-dry dressings, debridement, etc.)
    • The individual has received or participated in appropriate foot care (i.e., visual inspection, appropriate footwear, etc.)
  • Venous or arterial insufficiency ulcer and ALL of the following are met
    • Compression bandages and/or garments have been consistently applied
    • Leg elevation and ambulation have been encouraged
  • Surgically created wound or traumatic wound and ALL of the following are met
    • The wound requires accelerated formation of granulation tissue that cannot be achieved by other available topical wound treatments (e.g., comorbidities that prevent healing)
  • An ulcer or wound encountered in an inpatient setting and ONE or more of the following are met
    • Continuation of treatment is ordered beyond discharge to the home setting
    • Appropriate wound treatments have been tried or considered and ruled out, and NPWT 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) have occurred, and 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)

Note: The NPWT pumps/VAC must be prescribed by a physician and be capable of accommodating more than one (1) wound dressing set for multiple wounds on an individual. Therefore, more than one (1) pump billed per individual for the same time period is considered not medically necessary.

Negative pressure wound therapy not meeting the criteria as indicated in this policy is considered not medically necessary. 

Supplies

Supplies for negative pressure wound therapy are limited to the following. 

• Fifteen (15) dressing kits per month - Additional dressing kits per month must be supported by documentation that the wound size requires more than one dressing kit for each dressing change.
  
• Ten (10) canister sets per month - Additional canister sets per month must be supported by documentation that a large volume of drainage (greater than 90 ml of exudate per day) requires more than one canister set.

Negative pressure wound therapy supplies exceeding these limits are considered not medically necessary. 

Negative pressure wound therapy is considered not medically necessary when ONE or more of the following are met

• Adequate wound healing has occurred to the degree that NPWT pumps/VAC may be discontinued, in the judgment of the treating physician
• Any measurable degree of wound healing has failed to occur over the prior month as documented in the individual’s records
• Four (4) months (including the time NPWT was applied in an inpatient setting prior to discharge to the home) have elapsed using an NPWT pumps/VAC device in the treatment of any wound.

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

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