ModifiedOklahoma Health Care AuthorityPolicy N/A

Negative Pressure Wound Therapy

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This guideline governs medical necessity, prior authorization, documentation, utilization limits, continued medical necessity, and discontinuation of negative pressure wound therapy pumps and supplies for eligible ulcers, wounds, dehiscence, and graft-related injuries in home and inpatient settings.

Policy Summary

PayerOklahoma Health Care Authority

PolicyNegative Pressure Wound Therapy

Policy CodePolicy N/A

Change TypeRevision of existing criteria

Effective DateAugust 1, 2022

Next Review DateJuly 2025

Key ActionObtain prior authorization monthly for NPWT, with approval generally limited to a total of 4 months.

SourceLink

POLICY UPDATE CHANGES

The guideline is identified as a revision of existing NPWT criteria.

30 daysComplete wound therapy program before NPWT

4 monthsMaximum total NPWT approval period

15 kitsDressing kits per wound per month without additional documentation

4 setsCanister sets per month without additional documentation

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ModifiedOklahoma Health Care AuthorityPolicy N/A

Negative Pressure Wound Therapy

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Sign up for all Oklahoma Health Care Authority policy alerts

Know when Oklahoma Health Care Authority releases new policies or updates existing guidance.

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Policy Summary

PayerOklahoma Health Care Authority

PolicyNegative Pressure Wound Therapy

Policy CodePolicy N/A

Change TypeRevision of existing criteria

Effective DateAugust 1, 2022

Next Review DateJuly 2025

Key ActionObtain prior authorization monthly for NPWT, with approval generally limited to a total of 4 months.

SourceLink

POLICY UPDATE CHANGES

The guideline is identified as a revision of existing NPWT criteria.

30 daysComplete wound therapy program before NPWT

4 monthsMaximum total NPWT approval period

15 kitsDressing kits per wound per month without additional documentation

4 setsCanister sets per month without additional documentation

Weekly/monthlyWound access and reassessment cadence

>90 mL/dayExudate threshold for additional canister sets

NPWT Medical Necessity and Coverage Criteria

General Medical Necessity

Covered when medical necessity is established and the required objective documentation is submitted.

General prerequisites

Required prior wound status: Document that a 30-day complete wound therapy program was tried, including its results, plus either a chronic, non-healing ulcer with no improvement for at least the previous 30 days despite the program or a surgical or traumatic wound dehiscence with no improvement for at least the previous 30 days despite the program.30 days

Home-Setting Ulcers and Wounds

Covered in the home setting when the applicable chronic wound category and complete wound therapy program requirements are met.

Home-setting ulcer or wound

Complete wound therapy program
- General measures: Apply and document evaluation, care, and wound measurements by a licensed medical professional; moist wound dressings; debridement of necrotic tissue if present; adequate nutritional status; and either non-smoking status or, for a smoker, counseling on smoking’s effects on wound healing and the smoking-cessation treatments offered.
- Applicable etiology-specific measures
  - Stage 3 or 4 pressure ulcer: The member has been appropriately turned and positioned; has used a group 2 or 3 support surface for a posterior trunk or pelvic pressure ulcer; and has had moisture and incontinence appropriately managed.
  - Neuropathic ulcer: Pressure on a foot ulcer has been reduced with appropriate modalities and, if the member is diabetic, the member has been on a comprehensive diabetic management program.
  - Venous insufficiency ulcer: Compression bandages and/or garments have been consistently applied, and lower-extremity elevation and ambulation have been encouraged.

Surgical or Traumatic Wound Dehiscence

Covered for surgical or traumatic wound dehiscence after the required conservative wound program.

Wound dehiscence: A 30-day complete wound therapy program consisting of the applicable general measures described for ulcers and wounds must have been tried before NPWT is requested for a surgical or traumatic wound dehiscence.30 days

Traumatic Injury or Burn Resulting in Skin Graft

Covered for a traumatic injury or burn resulting in a skin graft when accelerated granulation is medically necessary and NPWT is placed immediately after grafting.

Skin graft following traumatic injury or burn: Document the medical necessity for accelerated formation of granulation tissue that cannot be achieved by other available topical wound treatments, and place NPWT immediately following grafting.Immediate placement following grafting

These skin grafts are exempt from the 30-day complete wound therapy program requirement.

Inpatient Ulcers and Wounds

Covered in the inpatient setting when one of the applicable wound categories and its requirements are met.

Inpatient wound categories

Chronic non-healing ulcer: Before NPWT, try a 30-day complete wound therapy program for a Stage 3 or Stage 4 pressure ulcer, venous or arterial insufficiency ulcer, or chronic mixed-etiology ulcer encountered in the inpatient setting.30 days
Surgical or traumatic wound dehiscence: Before NPWT, try a 30-day complete wound therapy program for the surgical or traumatic wound dehiscence.30 days
Traumatic injury or burn resulting in skin graft: Document the medical necessity for accelerated formation of granulation tissue that cannot be achieved by other available topical wound treatments and place NPWT immediately following grafting.

Continued Medical Necessity

Continued coverage requires ongoing professional wound management.

Continued medical necessity: For wounds treated with NPWT, a licensed medical professional must directly access the treated wound weekly, supervise or directly perform NPWT dressing changes, and document changes in wound dimensions and characteristics at least monthly.Weekly wound access; monthly documentation

Discontinuation Criteria

Treatment ends at the earliest occurrence of any discontinuation condition.

Discontinuation conditions: NPWT is discontinued when any of the following occurs: adequate healing has occurred in the treating physician’s judgment; measurable healing has failed during the prior month; four months have elapsed for the most recent wound; equipment or supplies are no longer being used; or continued medical necessity criteria cease to occur.Four months maximum for the most recent wound

Wound healing means improvement in surface area, calculated as length × width, or wound depth.

Discontinuation and Denial Criteria

NPWT pumps and supplies are denied as not medically necessary when any of the following occurs, whichever occurs earliest.

Discontinuation triggers

Adequate healing: In the treating physician’s judgment, adequate wound healing has occurred to the degree that NPWT may be discontinued.
No measurable healing: No measurable degree of wound healing has occurred over the prior month.Prior month
Wound healing means improvement in surface area, calculated as length × width, or wound depth.
Treatment duration elapsed: Four months have elapsed using an NPWT pump for the most recent wound, including NPWT applied in an inpatient setting before discharge to the home.4 months

NPWT is discontinued at the earliest occurrence of any applicable condition: adequate wound healing has occurred, measurable healing has not occurred during the prior 1 month, 4 months have elapsed for treatment of the most recent wound, equipment or supplies are no longer being used, or continued medical necessity criteria are no longer met. Measurable healing means improvement in wound surface area, calculated as length × width, or wound depth.

NPWT equipment and supplies are discontinued when they are no longer being used for the member, regardless of whether use was stopped by physician order. Continued billing is not supported once the equipment or supplies are no longer in use.

The NPWT pump and supplies will be denied as not medically necessary upon the earliest occurrence of any listed discontinuation condition. This includes adequate healing, failure to demonstrate measurable healing during the prior 1 month, completion of 4 months of treatment for the most recent wound, cessation of equipment or supply use, or failure to continue meeting medical necessity requirements.

Denial as not medically necessary applies when any of the following occurs, whichever is earliest: the treating physician determines that adequate wound healing has occurred and NPWT may be discontinued; no measurable wound healing has occurred over the prior 1 month; 4 months have elapsed using an NPWT pump for the most recent wound, including qualifying inpatient treatment before discharge home; the equipment or supplies are no longer being used for the member, whether or not use was discontinued by physician order; or the continued medical necessity criteria cease to be met. Wound healing is measured by improvement in surface area, calculated as length × width, or wound depth.

Covered Codes, Frequency Limits, and Treatment Parameters

CPT Codes Covered Requiring Prior Authorization - PumpHCPCSCovered

E2402

wound therapy pump (rental of 1 pump, PA required)

CPT Codes Covered Requiring Prior Authorization - SuppliesHCPCSCovered

A6550

wound therapy pump supplies (PA required to exceed 15 dressing kits per wound per month)

CPT Codes Covered Requiring Prior Authorization - CanisterHCPCSCovered

A7000

wound therapy pump canister (PA required to exceed 4 canister sets per month)

Dressing kits

Standard monthly limitUp to 15 dressing kits per wound per month.

Additional-kit documentationDocumentation must show that the wound size requires more than one dressing kit for each dressing change.

Prior authorizationPrior authorization is required when the limit is exceeded.

Canister sets

Standard monthly limitUp to 4 canister sets per month.

Additional-set documentationDocumentation must evidence a large volume of drainage greater than 90 mL of exudate per day.

Authorization, Documentation, and Review Requirements

Prior Authorization

Code-Specific Prior Authorization

Prior authorization is required for the negative pressure wound therapy pump and for supplies or canisters exceeding the stated monthly limits.

E2402: Wound therapy pump rental; prior authorization required.
A6550: Wound therapy pump supplies; prior authorization required for more than 15 dressing kits per wound per month.
A7000: Wound therapy pump canister; prior authorization required for more than 4 canister sets per month.
See the HCPCS book for complete code definitions.

Prior Authorization

Monthly Authorization and Four-Month Duration

Prior authorization is required monthly for NPWT and may be approved for a maximum total of four months, including NPWT received in the inpatient setting before discharge home.

E2402 rental authorization is required each month.

Negative Pressure Wound Therapy Overview

Negative pressure wound therapy applies sub-atmospheric pressure to a qualified wound through an integrated system consisting of a suction pump, exudate collection chamber, and dressing set. The system removes exudate and debris from the wound into the collection chamber. The guideline addresses NPWT in the treatment of chronic non-healing ulcers, wound dehiscence, and selected wounds associated with skin grafts when medical necessity is documented.

Clinical and Operational Definitions

Chronic wounds

DefinitionWounds that have failed to pass through the normal healing process in an orderly and timely manner and often remain in the inflammation phase.

Healing-stage detailA wound may be considered chronic if it has not entered the cellular migration and proliferation phase after 4 weeks.

Acute wounds

DefinitionWounds that transition through the normal healing process of homeostasis, inflammation, cellular migration and proliferation, and remodeling until the skin’s structure and function are restored.

Anastomosis

DefinitionThe union of blood vessels to interconnect.

Policy Summary

PayerOklahoma Health Care Authority

PolicyNegative Pressure Wound Therapy

Policy CodePolicy N/A

Change TypeRevision of existing criteria

Effective DateAugust 1, 2022

Next Review DateJuly 2025

Key ActionObtain prior authorization monthly for NPWT, with approval generally limited to a total of 4 months.

SourceLink

On This Page

Immediate placement following grafting

These skin grafts are exempt from the 30-day complete wound therapy program requirement.

Equipment no longer in use: The equipment or supplies are no longer being used for the member, whether or not use was discontinued by physician order.

Continued medical necessity no longer met: The criteria for continued medical necessity cease to occur.

Prior authorizationPrior authorization is required when the limit is exceeded.

Total treatment duration

Maximum total durationUp to a total of 4 months.

Inpatient treatment includedThe 4-month total includes NPWT applied in an inpatient setting before discharge to the home.

Authorization cadencePrior authorization is required monthly.

Wound access and reassessment

Direct wound accessA licensed medical professional must directly access the treated wound on a weekly basis.

Dressing-change oversightThe licensed medical professional must supervise or directly perform NPWT dressing changes.

Wound documentationChanges in wound dimensions and characteristics must be documented at least monthly.

NPWT treatment duration

Maximum treatment periodFour months for treatment of the most recent wound.

Inpatient NPWT includedThe period includes NPWT applied in an inpatient setting before discharge to the home.

Discontinuation pointTreatment is denied as not medically necessary when four months have elapsed, unless the request receives the required review.

Wound-healing assessment period

Required assessment periodMeasurable wound healing must occur over the prior month.

Meaning of healingWound healing is improvement in either surface area, calculated as length multiplied by width, or wound depth.

Failure to healAny measurable degree of wound healing that fails to occur over the prior month is a discontinuation and denial condition.

The four-month limit applies to treatment of the most recent wound and includes inpatient treatment before home discharge.

Prior Authorization

Beyond-Four-Month Review

Requests for NPWT beyond four months of treatment require Medical Director review before additional authorization can be considered.

Count inpatient NPWT before discharge toward the four-month treatment period.
Submit the clinical rationale and supporting records with the extended-treatment request.

Prior Authorization

Medical Director Review After Four Months

All PA requests extending NPWT beyond four months must be referred for Medical Director review rather than approved through routine authorization.

The review applies when four months have elapsed for the most recent wound, including inpatient NPWT.
Continued treatment remains subject to medical necessity and discontinuation criteria.

Step Therapy

Thirty-Day Complete Wound Therapy Program

Before applying NPWT, document a complete 30-day wound therapy program and its results. The program requires the general measures plus the applicable etiology-specific measures.

General measures are required for all ulcers and wounds.
For chronic ulcers, the wound must lack improvement for at least the preceding 30 days despite the complete program.
Surgical or traumatic wound dehiscence must likewise lack improvement for at least 30 days despite the program.
The program consists of criterion 3 plus the applicable pressure-ulcer, neuropathic-ulcer, or venous-insufficiency measures in criteria 4, 5, or 6.
The requirement applies in home and inpatient settings when specified; qualifying skin grafts are exempt.

Documentation Required

Medical Necessity and Failed Wound Therapy

Document objective records showing that medical necessity is met and that NPWT is the most cost-effective treatment for the member’s needs, consistent with OAC 317:30-3-1.

Document a chronic, non-healing ulcer or surgical/traumatic wound dehiscence with no improvement for at least 30 days despite the complete wound therapy program.
Include the results of the conservative wound therapy tried before NPWT.

Documentation Required

General Wound Documentation

For every ulcer or wound, document the evaluation, care, measurements, and conservative measures completed before NPWT.

A licensed medical professional must document wound evaluation, care, and measurements.
Apply dressings that maintain a moist wound environment.
Debride necrotic tissue when present.
Evaluate and provide for adequate nutritional status.
Document non-smoking status; for a smoker, document counseling about smoking’s effects on healing and the smoking-cessation treatments offered.

Documentation Required

Etiology-Specific Documentation

Add documentation specific to the wound etiology before requesting NPWT, including required pressure-ulcer, neuropathic-ulcer, or venous-insufficiency interventions.

Stage 3 or 4 pressure ulcer: Document appropriate turning and positioning, use of a group 2 or 3 support surface for posterior-trunk or pelvic ulcers, and management of moisture and incontinence.
Neuropathic ulcer: Document pressure reduction on a foot ulcer using appropriate modalities and, when diabetic, participation in a comprehensive diabetic management program.
Venous-insufficiency ulcer: Document consistent compression bandages or garments and encouragement of lower-extremity elevation and ambulation.

Documentation Required

Skin Graft Documentation

For a traumatic injury or burn resulting in a skin graft, document why accelerated granulation is medically necessary and cannot be achieved with other available topical wound treatments.

NPWT must be placed immediately following grafting.
Qualifying skin grafts are exempt from the 30-day complete wound therapy program requirement.
These requirements apply to qualifying cases in both home and inpatient settings.

Documentation Required

Continued Medical Necessity Documentation

When NPWT continues, maintain weekly and monthly records demonstrating ongoing access to, supervision of, and improvement in the treated wound.

A licensed medical professional must directly access the treated wound(s) weekly.
The professional must supervise or directly perform NPWT dressing changes.
At least monthly, document changes in wound dimensions and characteristics.

Denial Risk

Missing Required Conservative Wound Therapy

If the required 30-day complete wound therapy program was not tried, do not process the request as routine approval; defer it to a Medical Director for review.

The deferral applies to applicable home and inpatient requests for ulcers, wounds, and surgical or traumatic wound dehiscence.
Document why the conservative program was not completed and provide all available clinical records.

Documentation Required

Document Measurable Wound Progress

Document measurable wound progress during continued NPWT treatment. Healing is established by improvement in either wound surface area or wound depth.

Record wound dimensions and characteristics at least monthly.
A measurable change in length × width (surface area) or depth demonstrates progress.

Billing Rule

Excess Supply Utilization

Use quantities above the standard monthly limits only when the wound’s clinical needs are documented and prior authorization is obtained.

A6550 is limited to 15 dressing kits per wound per month unless documentation shows the wound requires more than one kit for each dressing change.
A7000 is limited to 4 canister sets per month unless documentation shows large-volume drainage greater than 90 mL of exudate per day.
Excess quantities require supporting records with the applicable PA request.

Denial Risk

Discontinuation or Loss of Medical Necessity

NPWT and related supplies must be discontinued or denied when the earliest applicable discontinuation condition occurs.

The treating physician determines that adequate healing has occurred for NPWT to stop.
No measurable healing occurs during the prior month.
Four months have elapsed for the most recent wound, including inpatient treatment before home discharge.
Equipment or supplies are no longer being used, whether or not discontinued by physician order.
Continued medical necessity requirements are no longer met.

Denial Risk

Discontinuation Criteria

Monitor for the provider-facing denial and discontinuation triggers throughout treatment and document the decision to continue or stop NPWT.

Stop when adequate healing has occurred.
Stop when there has been no measurable improvement in surface area or depth during the preceding month.
Stop at four months for the most recent wound unless further treatment is referred for Medical Director review.
Stop when equipment or supplies are no longer in use or when continued medical necessity criteria cease.

Documentation Required

Qualified Wound-Care Professional

A wound assessment or wound-care record must be completed by a professional licensed and qualified to assess wounds or administer wound care in the state where the member receives NPWT.

Acceptable licensed professionals may include an MD, DO, PA, APRN, RN, LPN, or PT.
The professional’s scope of practice must include wound assessment and/or wound care in the treatment state.

Documentation Required

Qualified Treating Practitioner

The treating practitioner responsible for the request and ongoing care must be state-licensed and qualified to assess wounds or administer wound care where NPWT is provided.

The guideline recognizes physicians, physician’s assistants, advanced practice registered nurses, registered nurses, licensed practical nurses, and physical therapists as licensed medical professionals when appropriately qualified.
Maintain evidence of applicable state licensure and wound-care qualifications.

Prior Authorization

Requests Outside the Guideline

Requests that do not conform to the guideline’s coverage, documentation, duration, or other requirements must be referred for Medical Director review.

Include objective medical records supporting the exception or nonconforming circumstance.
Routine approval is not available for requests outside the guideline.

Dehiscence

DefinitionThe parting of the sutured lips of a surgical wound.

Slough

DefinitionDead tissue separating from living tissue.

Fascia

DefinitionA sheet of connective tissue covering or binding together body structures.

Osteomyelitis

DefinitionAn infectious, usually painful inflammatory disease of bone.

Pressure ulcers (injuries)

DefinitionInjuries to skin and underlying tissue resulting from prolonged pressure on the skin.

Wound healing

DefinitionImprovement occurring in either the wound surface area, calculated as length multiplied by width, or the depth of the wound.

Licensed medical professional

Eligible professionalsA physician (MD or DO), physician’s assistant (PA), advanced practice registered nurse (APRN), registered nurse (RN), licensed practical nurse (LPN), or physical therapist (PT).

Licensure requirementThe professional must be licensed to assess wounds or administer wound care in the state where the member receives NPWT.