RetiredCareSourcePolicy MM-1144

Negative Pressure Wound Therapy ARPASSE MM-1144, MEDICAL POLICY STATEMENT AR PASSE

Defines CareSource medical policy for coverage, continuation, exclusions, supply allowances, and documentation requirements for Negative Pressure Wound Therapy (NPWT) including pressure ulcers, neuropathic, venous/arterial ulcers, post-surgical wounds, fractures, and amputations.

Policy Summary

PayerCareSource

PolicyNegative Pressure Wound Therapy ARPASSE MM-1144, MEDICAL POLICY STATEMENT AR PASSE

Policy CodePolicy MM-1144

Change TypeArchived (02/28/2023); Revised (02/02/2022); New (05/31/2018)

Effective DateMay 1, 2022

Next Review Date

Key ActionDocument prior conservative measures and ongoing compliance in the medical record to meet coverage criteria.

SourceLink

POLICY UPDATE CHANGES

Policy archived on 2023-02-28 and is no longer active.

Policy updated background and Section IIE on 2022-02-02.

Original policy issued 05/31/2018.

15Dressing kits allowed per wound per 31 days

10Canister sets allowed per 31 days

31Initial approval period (days)

2023-02-28Archived date

Coverage Summary

Subject: Negative Pressure Wound Therapy (NPWT). Payer: CareSource medical policy (MM-1144). Status: RETIRED. Effective date: 2022-05-01; Date archived: 2023-02-28.

Overview: This policy defined CareSource coverage criteria, continuation requirements, exclusions, supply allowances, and documentation requirements for NPWT (vacuum-assisted wound closure) used to treat pressure ulcers, neuropathic ulcers, venous/arterial insufficiency ulcers, selected post-surgical wounds, high-risk fractures, and open non-healing amputation sites. The policy established an initial implicit approval period of 31 days and specified supply limits and documentation needed for continuation or denial.

Surface thresholds and key numeric rules

dressing kits15 dressing kits per wound per 31 days

canister sets10 canister sets per 31 days

initial approval period31 days

archived date2023-02-28

Medical-Necessity Criteria

Medically Necessary Indications - General

CareSource considers NPWT medically necessary when the following clinical criteria are met:

ALL of the following

Stage III or IV pressure ulcer (see staging criteria in Definitions)
ONE of the following eligible conditions
- Member has been on every 2-hour turning and repositioning regimen
- Member's incontinence and moisture issues have been appropriately managed
- Pressure relief techniques and/or pressure-reducing surfaces have been ordered and documented with ongoing compliance in the medical record (e.g., foam overlay mattress, egg crate foam mattress, low-air-loss devices)

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Chronic Neuropathic Ulcer

NPWT is medically necessary for chronic neuropathic ulcer when BOTH criteria are met:

ALL of the following

A comprehensive diabetic management program has been implemented including A1C management, medication management and ongoing diabetic education
Foot care has been done by a medical professional to include general inspection, nail care, reduction in pressure on foot ulcer, and monofilament testing

Ulcers Related to Venous or Arterial Insufficiency

NPWT is medically necessary when ALL of the following are met:

ALL of the following

Compression garments/dressing/bandages are being applied consistently per physician orders in documented plan of care for at least thirty days (venous insufficiency)
Ambulation and leg elevation have been ordered and documented with ongoing compliance in the member medical record

Other Covered Indications

NPWT is considered medically necessary for the following situations (each listed as a covered indication):

ANY of the following

High-risk open fracture
Post sternotomy wound complication or infection (mediastinitis)
Wound that has dehisced (separation of a previously closed surgical incision)
Surgically created wound with complications requiring accelerated granulation therapy not achievable by other modalities
Delayed healing or non-healing of skin graft likely due to irregular contour or inadequate blood flow from graft bed

Continuation of NPWT

Members may be eligible for continuation when documentation by a licensed medical professional includes ALL of the following:

ALL of the following

Documentation that a licensed medical professional has directly performed the dressing change
Wound has progressive and measurable improvement
Measurable improvement defined as changes in drainage, inflammation, swelling, pain/tenderness, wound dimensions (length x width), depth, granulation tissue, necrotic tissue/slough, tunneling or undermining
If wound was debrided within the last approval period, documentation of debridement must accompany the continuation request; before and after images are preferred
Exception to measurable improvement when debridement occurred within last approval period
If no measurable improvement month-to-month, approval for NPWT will be discontinued

Provider Actions

Documentation Required

Document conservative measures and compliance

Document prior conservative measures and ongoing compliance in the medical record to meet coverage criteria. Include documentation of turning/repositioning every 2 hours, incontinence and moisture management, ordered pressure relief techniques or pressure-reducing surfaces (e.g., foam overlay mattress, egg crate foam, low-air-loss devices), and evidence of continued adherence to these measures.

Turning/repositioning every 2 hours
Incontinence/moisture management
Pressure relief surfaces and orders
Ongoing compliance documented

Documentation Required

Diabetic management and foot care documentation

For neuropathic (diabetic) foot ulcers, document a comprehensive diabetic management program including A1C management, medication management, and ongoing diabetic education. Also document foot care performed by a medical professional including general inspection, nail care, measures to reduce pressure on the ulcer, and monofilament testing.

A1C management
Medication management
Ongoing diabetic education
Foot care by medical professional (inspection, nail care)
Monofilament testing and pressure reduction measures

Prior Authorization

Initial and continuation approvals

Initial approval is implicit for a 31-day period. For continuation requests, submit documentation that a licensed medical professional directly performed the dressing changes and evidence of measurable wound improvement (changes in drainage, inflammation, swelling, pain/tenderness, wound dimensions, depth, granulation tissue, necrotic tissue/slough, tunneling or undermining) or, if applicable, documentation of debridement from the prior approval period.

Implicit initial 31-day approval
Licensed clinician directly performed dressing changes
Measurable improvement documented (specified wound parameters)
If debridement occurred, include debridement documentation

Denial Risk

Discontinue if no improvement

Approval for NPWT will be discontinued if there is no measurable degree of improvement in wound healing from month to month.

Documentation Required

Debridement exception

If a wound was debrided within the last approval period, attach documentation of the debridement with the continuation request. Before-and-after images are preferred when applicable to support the continuation request.

Attach debridement documentation with continuation requests
Before-and-after images preferred when available

Background, Evidence & Definitions

Background: Negative Pressure Wound Therapy (NPWT), also known as vacuum-assisted wound closure, applies controlled subatmospheric pressure to a wound using an electrical pump connected to a specialized semipermeable dressing that removes debris and exudate into a collection canister and promotes a moist, warm environment conducive to healing. NPWT is a noninvasive therapy performed in the home or outpatient settings and typically does not require inpatient monitoring.

Common uses: NPWT is used for chronic wounds including pressure ulcers (staged per policy definitions), neuropathic ulcers, and venous or arterial insufficiency ulcers, as well as selected post-surgical wounds, wounds that have dehisced, high-risk open fractures, delayed or non-healing skin grafts, post-sternotomy wound complications, and open non-healing amputation sites in diabetic patients.

Source	Citation
Cochrane review	Webster J et al. Negative pressure wound therapy for surgical wounds healing by primary closure. Cochrane Database Syst Rev 2019; CD009261.
Systematic review	Peinemann F, Sauerland S. Negative-Pressure Wound Therapy: Systematic Review of Randomized Controlled Trials. Deutsches Arzteblatt Int. 2011;108(22).

Term	Definition
Stage III pressure ulcer	Full-thickness skin loss with visible adipose (fat) tissue and granulation; may have rolled edges, possible eschar/slough; no exposed fascia, muscle, tendon, ligament, cartilage, or bone.
Stage IV pressure ulcer	Full-thickness tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone; often with eschar/slough and undermining/tunneling.
Deep Tissue Pressure Injury (DTI)	Injury with necrosis of underlying soft tissue presenting as a blood blister or dark wound bed; may be covered in thin eschar.
Slough	Avascular (dead) soft tissue found in higher stage ulcers.
Eschar	Black or brown, thick leathery dead tissue covering an ulcer.

OpenPayer

Negative Pressure Wound Therapy ARPASSE MM-1144, MEDICAL POLICY STATEMENT AR PASSE

Coverage Summary

Medical-Necessity Criteria

Not Medically Necessary / Exclusions

Intraoperative & Reimbursement Rules

Coding & Supply Allowances

Provider Actions

Background, Evidence & Definitions

Revision History

	15 dressing kits per wound per 31 days
	10 canister sets per 31 days
	Additional dressing kits may be requested with documentation that wound size requires more than one kit