Medical Technologies & Procedures

Negative Pressure Wound Therapy

Coverage decision

Negative Pressure Wound Therapy (NPWT) is covered with conditions, when the wound is related to an injury or illness allowed on the claim.

NPWT is used in carefully selected patients whose wounds are not responsive to standard forms of treatment, or are at high risk of failing to heal as described below.

Indications for use:

  1. Stage III or IV pressure ulcer
  2. Diabetic/Neuropathic ulcer
  3. Venous or arterial insufficiency ulcer
  4. Chronic ulcers of mixed etiology present for at least 30 days
  5. Acute wounds induced by trauma or surgery
  6. Wounds that have received skin grafts, where there are medical factors that are likely to slow or prevent healing
  7. Poststernotomy mediastinitis, inpatient only

Non-covered indications:

  1. Necrotic tissue with eschar present
  2. Untreated osteomyelitis
  3. Non-enteric and unexplored fistulas
  4. Malignancy in the wound
  5. Exposed vasculature, nerves, or anastomotic site
  6. Exposed organs

NPWT should not be used for wounds that would otherwise be expected to heal by standard methods.

Risk factors to consider before NPWT use; use in these conditions is not covered unless a medical provider provides a clear justification for the risk:

  1. Patients at high risk for bleeding and hemorrhage
  2. Patients on anticoagulants or platelet aggregation inhibitors
  3. Patients with:
    • a.   Friable vessels and infected blood vessels,
    • b.  Vascular anastomosis,
    • c.  Infected wounds,
    • d.  Osteomyelitis,
    • e.  Exposed organs, vessels, nerves, tendons and ligaments,
    • f.  Sharp edges in the wound (i.e. bone fragments),
    • g.  Enteric fistulas
  4. Patients requiring MRI, hyperbaric oxygen therapy, defibrillation
  5. Use near vagus nerve
  6. Circumferential dressing application
  7. Patients at home without professional home health care services

Prior authorization is required. Before starting NPWT, and every 30 days thereafter, providers must submit clinical notes that include the following criteria:

  1. Type of wound, e.g. surgical, pressure ulcer, neuropathic ulcer, etc.
  2. History of the wound (date of onset) ,the treatments used and why they were not successful
  3. Detailed current wound condition, including:
    • a.  Location
    • b.  Size (length and width)
    • c.  Depth
    • d.  Stage
    • e.  Tunneling
    • f.  Drainage
    • g.  Presence of any contraindications or risk factors as described above
  4. The patient’s general health and nutritional status, with lab values including:
    • a.  Albumin, should be ≥3.0
    • b.  Hemoglobin, should be ≥10.0
    • c.  HgbA1C if indicated, should be ≤8.0
  5. A plan for use of the NPWT, including an estimate of the time it will be needed, and indications that will be used for discontinuation

Time limit: In most cases, NPWT will be needed for 2 weeks-2 months. Further authorization will be given only if wound healing is evident, and all the above criteria are met.

Equipment limits: Patients are allowed one NPWT pump per episode (a pump may be used for more than one wound at the same time). Supplies should be limited to 15 dressing kits per wound per month, and 10 canister sets per month.

Non-powered NPWT systems (e.g. SNaP) may be considered on a case-by-case basis.

HCPCS codes:

E2402 (rent only, unit of service is one day)

A6550 (dressing kits)

A7000 (canister sets)

For more information:
Contact information.

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