Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy
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Defines the health plan coverage stance for use of low-frequency (noncontact) ultrasound wound therapy and noncontact normothermic wound therapy for wound management for members/enrollees of Centene-affiliated health plans.
No material clinical or coverage changes in this revision.
Coverage Determinations
Not supported (general)
Not Medically Necessary / Not Supported when the following policy positions apply:
These are the explicit policy positions stated by the plan.
Summarizes supporting evidence referenced in the policy.
The policy does not list any specific indications in which low-frequency ultrasound wound therapy or noncontact normothermic wound therapy (NNWT) are covered. Instead, the plan’s position is a general non-support stance: current evidence does not support the use of low-frequency ultrasound wound therapy and current evidence does not support the use of NNWT for wound management. As a result, there are no narrowly defined, supported clinical scenarios or criteria in this policy that would render these therapies medically necessary.
Where state Medicaid coverage provisions conflict with this clinical policy, state Medicaid coverage provisions take precedence. Providers should consult the applicable state Medicaid manual for specific Medicaid coverage rules and follow those rules for Medicaid members/enrollees.
In summary, the plan’s clinical assessment concludes that the current evidence does not support the use of low-frequency ultrasound wound therapy or noncontact normothermic wound therapy (NNWT); these therapies are not considered supported by the evidence cited in this policy.
Relevant Billing Codes
| 97610 | Low frequency, non-contact, non-thermal ultrasound, including topical application(s) when performed, wound assessment, and instruction(s) for ongoing care; per day |
| 97610 | Low-frequency, non-contact, non-thermal ultrasound (as referenced) |
Provider Responsibilities & Billing Guidance
Prior Authorization Required
Prior authorization requirements may apply for the CPT/HCPCS codes referenced in this policy. Providers must follow Arizona Complete Health's plan-specific prior authorization processes before rendering services associated with these codes.
Prior Authorization Guidance
This clinical policy provides medical necessity guidance that may be used to inform prior authorization determinations. Use the criteria in this policy as part of the review, but confirm and apply any additional plan-specific prior authorization rules or forms.
Denial Risk — Low-Frequency Ultrasound
Current evidence does not support the use of low-frequency, non-contact, non-thermal ultrasound wound therapy. Claims for this therapy are at increased risk of denial when supporting clinical evidence and documentation are insufficient.
Documentation & Coding Reminder
When submitting claims for services referenced in this policy, include the relevant CPT/HCPCS codes and complete supporting clinical documentation that demonstrates medical necessity and adherence to plan criteria. Inclusion of codes in this policy is informational and does not guarantee coverage.
Coverage Decisions & Administration of Benefits
Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the member's coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance) and applicable state and federal requirements. This clinical policy is a guide to medical necessity and does not guarantee payment.
Review Applicable CMS NCDs/LCDs
Providers should review applicable CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs) and Local Coverage Articles (e.g., LCD A56175 and related articles) prior to applying this clinical policy to Medicare members. Ensure consistency with current CMS guidance.
Definitions and Key Terms
Clinical Background
Chronic and difficult-to-heal wounds require an environment that supports tissue repair: a well-vascularized, debrided, infection-controlled, and moist wound bed. Surgical debridement is indicated when there is extensive necrotic tissue or clinical infection requiring operative removal. Adjunctive therapies are intended to support these fundamental requirements by removing devitalized tissue, reducing bioburden, and optimizing the wound bed. Low-frequency ultrasound debridement is a noncontact method that uses ultrasound to atomize saline into a continuous mist directed at the wound from a short distance to provide cleansing and debridement, while NNWT (noncontact normothermic wound therapy) maintains a warm, humid microenvironment over the wound to promote conditions favorable for healing. The available evidence, however, as summarized in this policy, was judged insufficient to demonstrate consistent clinical benefit for these modalities compared with established wound care practices.
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