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 the device to promote wound healing. 

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 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
  • Non-healing wound with a small amount of exudate
  • Surgically closed incision
• None of the following are present
  • Actively infected ulcer
  • Actively bleeding ulcer
  • Inadequately drained ulcer
  • Inadequately debrided ulcer
  • Exposed blood vessels, anastomotic sites, organs, tendons, or nerves
  • Ulcer containing malignancy
  • Fistula
  • Untreated osteomyelitis within the vicinity of the ulcer
• Once placed on a non-powered NPWT system, a licensed medical professional will do ALL of the following
  • Directly assess the ulcer(s) being treated with the non-powered NPWT system
  • Document changes in the ulcer’s dimension and characteristics at least monthly

Note: A licensed health care professional, for the purposes of this policy, may be a physician, physician's assistant (PA), certified registered nurse practitioner (CRNP), 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 individual is receiving non-powered NPWT.

The non-powered NPWT system and supplies is considered not medically necessary when ONE or more of the following are met

• Adequate ulcer healing has occurred to the degree that non-powered NPWT may be discontinued, in the judgment of the treating physician
• Any measurable degree of ulcer healing has failed to occur over the prior month as documented in the individual’s records
• 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 four (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.

Supplies

Supplies for non-powered NPWT are limited to the following

• 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’s medical record and must be available upon request. 
• Strap – one (1) per episode of treatment

Non-powered negative pressure wound therapy supplies exceeding these limits are considered not medically necessary. 

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.