Negative Pressure Wound Therapy (NPWT) (Vacuum-Assisted Wound Closure)
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Medical necessity and coverage policy for negative pressure wound therapy (vacuum-assisted wound closure) including indications, coverage criteria, coding, and prior authorization documentation requirements for Moda Health Plan Inc members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Negative Pressure Wound Therapy (NPWT)
Initial Therapy Indications
Moda Health considers NPWT medically indicated when ALL of the following are present:
Primary conditions for trial
- Qualifying wound examples: 1) Following skin graft or dermal substitute for acute or chronic wounds; 2) Diabetic ulcer or wound meeting one or more criteria: (a) Wagner or University of Texas classification grade 1 that has not responded to conventional treatment after 30 days, or (b) Wagner or University of Texas classification grade 2 or greater; 3) Traumatic or surgical wounds with one or more of: delayed primary closure, dehiscence, exposed bone/cartilage/tendon/foreign material, inpatient wound where other treatments tried/ruled out and NPWT is considered by treating physician the best option, or sternal infection following cardiovascular surgery;30 days
See policy text for diabetes classification specifics and inpatient wound considerations.
Pressure Ulcers
Pressure ulcers: Covered when ALL of the following are present:
Optimal care includes appropriate turning and positioning, use of a support surface for posterior trunk/pelvis (e.g., mattress overlay, alternating pressure, low air loss), and appropriate management of moisture and incontinence.
Venous Insufficiency Ulcers
Venous insufficiency ulcers: Covered when ALL of the following are met:
Conservative measures must include consistent application of compression bandages and/or garments and encouragement of leg elevation and ambulation when applicable; document failure after 90 days.
Continuation Therapy
Continuation of NPWT is indicated when ALL of the following are met:
Documentation of wound measurements and progressive healing must occur at least monthly. Failure to show measurable healing over the prior month makes NPWT not medically necessary.
Duration and Discontinuation
Duration and discontinuation:
Includes requirement that conventional wound management continues; contraindications that preclude use include active bleeding, exposed cortical bone/nerves/organs, malignancy in the wound, uncontrolled infection/osteomyelitis, or unexplored fistulae (see policy for full list).
Disposable and non-powered wound suction pumps and their related supplies are not medically necessary and not covered. Examples identified in this policy include the PICO Single Use Negative Pressure Wound Therapy System and the SNaP Wound Care System, and the associated HCPCS/CPT codes listed as not covered include A9272, 97607, and 97608.
Negative pressure wound therapy (pump and supplies) is considered not medically necessary if any measurable degree of wound healing has failed to occur over the prior month. Discontinuation is also appropriate when the treating physician documents that adequate healing has occurred; wound healing is defined as improvement in either surface area or depth.
Coding, Durations, and Applicable Diagnosis Codes
| 97605 | Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters. |
| 97606 | Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters. |
| A6550 | Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories. |
| A7000 | Canister, disposable, used with suction pump, each. |
| 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 pad size 16 square inches or less. |
| K0745 | Absorptive wound dressing for use with suction pump, home model, portable pad size more than 16 square inches but less than or equal to 48 square inches. |
| K0746 | Absorptive wound dressing for use with suction pump, home model, portable, pad size greater than 48 square inches. |
| A9272 | Wound suction, disposable, includes dressing, all accessories and components, any type, each. |
| 97607 | Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters. |
| 97608 | Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters. |
| E10.40-E10.49 | Type 1 diabetes mellitus with diabetic neuropathy. |
| E11.40-E11.49 | Type 2 diabetes mellitus with diabetic neuropathy. |
| E10.51-E10.59 | Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene. |
| E11.51-E11.59 | Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene. |
| I70.231-I70.25 | Atherosclerosis of native arteries of extremities with ulceration. |
| L89.003-L89.894 | Pressure ulcer stage III or IV. |
| S21.101-S21.149 | Open wound of chest (wall), complicated [deep sternal wound infection]. |
| T81.31-T81.32x | Disruption of external or internal operation (surgical) wound. |
Provider Requirements, Prior Authorization, and Documentation
Submit medical records and applicable CPT/HCPCS codes with prior authorization
Prior authorization must include submission of the patient’s medical records showing wound evaluations, wound measurements, and a record of treatment goals. Use the following covered CPT/HCPCS codes when requesting authorization: 97605, 97606, A6550, A7000, E2402, K0743, K0744, K0745, and K0746.
Initial 30-day therapeutic trial; continuation requires documented healing
An initial therapeutic trial of NPWT is limited to 30 days. Continuation beyond the initial 30-day trial requires documentation of one or more signs of healing (development of granulation tissue, decreasing wound size or depth, or epithelial spread) and monthly documentation by a licensed provider demonstrating progressive healing.
- Initial trial duration: 30 days
- Continuation requires at least one sign of healing documented during the trial
- Licensed provider must document wound dimension/characteristic changes at least monthly
Provide patient evaluation, wound measurements, and treatment goals
Include the patient’s medical records of evaluation and care, wound measurements, and a record of treatment goals with the prior authorization request. Documentation must show wound measurements and progressive healing at least monthly.
- Patient medical records of evaluation and care
- Wound measurements (recorded and tracked)
- Treatment goals for NPWT
- Monthly documentation of wound measurements and progressive healing
Denial if no measurable healing in prior month; disposable systems not covered
NPWT pumps and supplies will be considered not medically necessary if any measurable degree of wound healing has failed to occur over the prior month; in such cases coverage will be denied.
- Lack of measurable healing over the previous month is a trigger for non‑coverage
- Disposable and non‑powered wound suction pumps (e.g., PICO, SNaP) and related supplies are not covered
Definitions and Background on NPWT
Negative Pressure Wound Therapy (NPWT) is a therapeutic technique that applies controlled suction to a wound to remove fluids, debris, and infectious material and to promote formation of granulation tissue. It may be used adjunctively with surgical therapy or as an alternative in patients who are debilitated. Clinical indications described in the policy include use at post-skin graft or dermal substitute sites, appropriately classified diabetic ulcers unresponsive to conservative care, traumatic or surgical wounds with delayed closure or exposed structures, complicated sternal infections after cardiac surgery, and pressure ulcers (Stage III or IV) or venous insufficiency ulcers that have failed to heal after appropriate conservative measures.
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