EmblemHealth NPWT Coverage Update: Prior Auth

Coverage and Medical Necessity Criteria

Initial Therapy Coverage Criteria

Covered when ALL of the following are met

Overall eligibility: Member has DME benefit and wound meets a qualifying wound type: chronic stage III or IV pressure ulcer; neuropathic (e.g., diabetic) ulcer; venous or arterial insufficiency ulcer; or a chronic ulcer present >= 30 days. Note: the 30-day waiting period is waived for members with seronegative arthropathies and connective tissue disorder comorbidities in conjunction with acute wounds.

Complete wound therapy program: A complete wound therapy program applicable to the wound type has been ruled out or attempted unsuccessfully prior to NPWT initiation. The program must include determination of etiology and prior appropriate treatment; application of dressings to ensure appropriate wound moisture; documentation of the wound (see Wound Documentation); debridement of necrotic tissue as appropriate; documentation of wound onset date; and evaluation of, and provision for, adequate nutritional status.

Wound-type specific prerequisites: Specific conservative measures must have been attempted (unless contraindicated): for stage III/IV pressure ulcers — appropriate turning/repositioning and prior use of a group 2 or 3 support surface for posterior trunk/pelvis pressure ulcers, and appropriate moisture/incontinence management; for neuropathic ulcers — comprehensive diabetes management and foot-ulcer pressure reduction (e.g., contact casting or other pressure-relief methods) with the foot well vascularized; for venous insufficiency ulcers — compression bandages/garments (eg, Unna boot), documented leg elevation and ambulation, and maximal therapy for edema and swelling for >= 30 days prior to NPWT initiation.

Inpatient-specific indication: For inpatient wounds, NPWT may be initiated at the treating physician's judgment. Indications include complications of surgically created wounds (eg, dehiscence) or traumatic wounds where accelerated granulation tissue formation is medically necessary and cannot be achieved by other topical treatments.

Continuation / Discontinuation Criteria

Continuation and duration considerations

Ongoing documentation and monitoring: Ongoing wound care must be provided by a licensed health care provider with documentation of quantitative wound measurements and dated wound characteristics (including photographs) updated regularly and demonstrating progressive month-to-month healing.

Duration: While the majority of patients with stage III and IV ulcers achieve sufficient wound closure within 6 weeks, coverage beyond 4 months is generally not considered medically necessary. Extensions may be considered with additional required documentation and individualized clinical justification.

Discontinuation triggers: NPWT may be discontinued when applicable, including: physician-performed serial debridements (3–4 times) within 90 days; failure of any measurable degree of wound healing within 1 month (grafts should heal in 7 days and no later than 1 month); no further change in wound depth; member noncompliance; presence of sloughing > 20%; or absence of a full-thickness wound.

Covered Diagnoses

Covered when diagnosis matches one of the listed ICD-10 codes and policy-specific clinical criteria are met.

Diagnosis match: Presence of an ICD-10 diagnosis code from the policy's listed codes such as pressure ulcer codes in the L89.* range, non-pressure chronic ulcer codes in the L97.* or L98.* ranges, or graft complication codes T86.* (see policy ICD-10 code list for specific codes).

Exact clinical entry criteria and combinatorial logic are described in the policy; documentation must support the selected diagnosis code when requesting therapy.

Disposable single-use, battery-powered negative-pressure wound therapy (NPWT) systems (examples: PICO™, Prevena™, V.A.C. Via™, MyNeWT, Uno) are listed in the policy Limitations/Exclusions as experimental, investigational, or unproven for any indication. The policy also identifies specific procedure and supply codes associated with these disposable systems (e.g., CPT codes 97607 and 97608, and HCPCS code A9272) as experimental/investigational when submitted for coverage.

The policy revision history notes that investigational device examples and their applicable coding were added to the Limitations/Exclusions section (see revision entry 08/11/2023), and the Limitations/Exclusions list explicitly names disposable single-use NPWT systems as experimental/investigational. These investigational devices and their associated codes are therefore excluded from coverage and may be denied if billed.

NPWT is not medically necessary when the policy criteria are not met or when the wound has one of the following conditions: cancer in the wound, necrotic tissue with eschar, untreated osteomyelitis within the vicinity of the wound, or a fistula to an organ or body cavity within the vicinity of the wound. These situations are listed in the Limitations/Exclusions section as contraindications to coverage.

Devices and indications that are explicitly labeled as investigational in the Limitations/Exclusions section are considered not medically necessary for coverage. The policy revision history documents the addition of investigational device examples and the Limitations/Exclusions section specifically identifies associated codes (e.g., CPT 97607, 97608, HCPCS A9272) as experimental/investigational and therefore noncovered.

Procedure, Supply, and Diagnosis Codes

Applicable Procedure and Supply CodesmixedCovered

97605	Negative pressure wound therapy, total wound(s) surface area <= 50 sq cm
97606	Negative pressure wound therapy, total wound(s) surface area > 50 sq cm
A6550	Wound care set for negative pressure wound therapy electrical pump
E2402	Negative pressure wound therapy electrical pump, stationary or portable
K0743	Suction pump, home model, portable, for use on wounds
K0744	Absorptive wound dressing for use with suction pump, home model, portable, size <=16 sq in
K0745	Absorptive wound dressing for use with suction pump, home model, portable, size >16 sq in and <=48 sq in
K0746	Absorptive wound dressing for use with suction pump, home model, portable, size >48 sq in

Codes considered experimental, investigational or unprovenmixedExperimental

97607	Negative-pressure wound therapy - listed as experimental/investigational in document
97608	Negative-pressure wound therapy - listed as experimental/investigational in document
A9272	Disposable single-use NPWT system - listed as experimental/investigational in document

Applicable ICD-10 Diagnosis Codes (partial list shown in document)ICD-10

E08.621	Diabetes mellitus due to underlying condition with foot ulcer
E08.622	Diabetes mellitus due to underlying condition with other skin ulcer
E09.621	Drug or chemical induced diabetes mellitus with foot ulcer
E09.622	Drug or chemical induced diabetes mellitus with other skin ulcer
E10.621	Type 1 diabetes mellitus with foot ulcer
E10.622	Type 1 diabetes mellitus with other skin ulcer
E11.621	Type 2 diabetes mellitus with foot ulcer
E11.622	Type 2 diabetes mellitus with other skin ulcer
E13.621	Other specified diabetes mellitus with foot ulcer
E13.622	Other specified diabetes mellitus with other skin ulcer

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Applicable ICD-10 Diagnosis Codes (selected excerpts)ICD-10

L89.116	Pressure-induced deep tissue damage of right upper back
L89.123	Pressure ulcer of left upper back, stage 3
L89.124	Pressure ulcer of left upper back, stage 4
L89.126	Pressure-induced deep tissue damage of left upper back
L89.133	Pressure ulcer of right lower back, stage 3
L89.134	Pressure ulcer of right lower back, stage 4
L89.136	Pressure-induced deep tissue damage of right lower back
L89.143	Pressure ulcer of left lower back, stage 3
L89.144	Pressure ulcer of left lower back, stage 4
L89.146	Pressure-induced deep tissue damage of left lower back

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Wound surface area — CPT coding

CPT 97605Negative pressure wound therapy — total wound surface area <= 50 sq cm (per session)

CPT 97606Negative pressure wound therapy — total wound surface area > 50 sq cm (per session)

Associated supply codesA6550 (wound care set for NPWT), E2402 (NPWT electrical pump)

Dressing supply codesK0744 (<=16 sq in), K0745 (>16 & <=48 sq in), K0746 (>48 sq in)

Waiting period waiver

Standard waiting period30-day minimum chronic wound duration before NPWT eligibility (policy default)

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required. The treating physician or primary care provider must submit clinical evidence demonstrating the patient meets policy criteria. Failure to submit required clinical documentation (including wound documentation listed below) will prevent proper prior authorization processing.

Prior authorization with submission of clinical documentation showing eligibility criteria are met
Include wound documentation per policy (see Wound Documentation callouts)

Prior Authorization

Prior Authorization Guidance

References Noridian LCD for Negative Pressure Wound Therapy Pumps and the policy revision history. Prior authorization may be required per payer and LCD guidance.

Noridian LCD for Negative Pressure Wound Therapy Pumps (Jan 2024) — consult for coding/coverage nuances
Revision history notes additions to indications and investigational device examples

Background and Policy Context

Negative-pressure wound therapy (NPWT), also called vacuum-assisted wound closure, applies controlled negative pressure to a wound using an electrical pump and an occlusive dressing. The therapy promotes healing by removing interstitial fluid, reducing bacterial colonization, increasing local vascularity, and stimulating tissue approximation to support granulation and wound closure. NPWT may be applied in inpatient or outpatient settings and is considered when appropriate conservative wound care has been attempted or deemed unsuitable.

Definitions and Coding Notes

Negative-pressure wound therapy (NPWT) — definition

DefinitionControlled application of negative pressure to a wound with an electrical pump that intermittently or continuously conveys negative pressure through tubing to a specialized occlusive dressing to promote healing (removes interstitial fluid, increases vascularity, decreases bacterial colonization, and stimulates tissue approximation)

Alternate nameAlso referred to as vacuum-assisted wound closure (VAC)

SettingsMay be used in inpatient or outpatient settings, including lightweight versions

T86.* — skin graft complication codes

T86.820Skin graft (allograft) rejection

T86.821Skin graft (allograft) (autograft) failure

Revision History and Policy Changes

2024-04-12Material additionLatest

Added indication for wounds secondary to peripheral arterial disease.

2023-08-11Clarification - investigational devices

Added investigational device examples with applicable coding to Limitations/Exclusions section.

2021-04-09Coverage expansion

OpenPayer

Vacuum-Assisted Wound Closure (Negative-Pressure Wound Therapy)