CurrentRegence BlueCross BlueShieldPolicy M-DME42

Negative Pressure Wound Therapy in the Outpatient Setting

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Medicare Advantage coverage, prior authorization, documentation, and coding requirements for negative pressure wound therapy in outpatient, home-health, physician-office, and home settings.

Policy Summary

PayerRegence BlueCross BlueShield

PolicyNegative Pressure Wound Therapy in the Outpatient Setting

Policy CodePolicy M-DME42

Change TypeNo material change

Effective Date04/01/2026

Last ReviewFeb 1, 2026

Next Review Date12/01/2026

Key ActionObtain preauthorization for the initial one-month therapeutic trial and each subsequent month beginning on day 31.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4 monthsMaximum therapeutic trial

Day 31Continuation authorization begins

MonthlyWound measurements

50 cm²Surface-area threshold

A9272

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CurrentRegence BlueCross BlueShieldPolicy M-DME42

Negative Pressure Wound Therapy in the Outpatient Setting

Customize your policy alerts

Sign up for regence Policy M-DME42 alerts

Get alerted when Policy M-DME42 changes without checking for updates manually.

Monitor payer policy activity

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Medicare Advantage coverage, prior authorization, documentation, and coding requirements for negative pressure wound therapy in outpatient, home-health, physician-office, and home settings.

Policy Summary

PayerRegence BlueCross BlueShield

PolicyNegative Pressure Wound Therapy in the Outpatient Setting

Policy CodePolicy M-DME42

Change TypeNo material change

Effective Date04/01/2026

Last ReviewFeb 1, 2026

Next Review Date12/01/2026

Key ActionObtain preauthorization for the initial one-month therapeutic trial and each subsequent month beginning on day 31.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4 monthsMaximum therapeutic trial

Day 31Continuation authorization begins

MonthlyWound measurements

50 cm²Surface-area threshold

A9272

Disposable home-use code

Coverage Criteria

Documentation Supporting Medical Necessity

The information below must be submitted for review to determine whether policy criteria are met. If any of these items are not submitted, it could impact our review and decision outcome.

Required documentation

Information describing the history, previous treatment regimens (if applicable), and current wound management for which a NPWT pump is being billed, including length of sessions of use, dressing types and frequency of change, and changes in wound conditions, including precise measurements, quantity of exudates, presence of granulation and necrotic tissue, and concurrent measures being addressed relevant to wound therapy.
Information describing regular evaluation and treatment of the beneficiary's wounds.
Documentation of quantitative measurements of wound characteristics, including wound length and width (surface area), depth, and amount of wound exudate (drainage), indicating progress of healing, must be entered at least monthly. The supplier of the NPWT equipment and supplies must obtain from the treating clinician an assessment of wound healing progress, based upon the wound measurement as documented in the beneficiary's medical record, in order to determine Medicare coverage.
Month-to-month comparisons of wound size must compare like measurements; for example, depth compared to depth or surface area compared to surface area.

Disposable NPWT systems are not eligible for coverage as DME when used by the member in the home setting, in the absence of a home health plan. However, disposable NPWT may be eligible for coverage when requested as part of a service in a home health plan or when provided in a physician's office.

Coding and Billing Requirements

NPWT procedure codesCPTCovered

97605	Negative pressure wound therapy (e.g., 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
97606	Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters
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)
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

NPWT equipment and suppliesHCPCSCovered

E2402	Negative pressure wound therapy electrical pump, stationary or portable
A6550	Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories
A7000	Canister, disposable, used with suction pump, each
A7001	Canister, nondisposable, used with suction pump, each
K0743	Suction pump, home model, portable, for use on wounds

Disposable NPWT home-use billingHCPCSCovered

A9272

Disposable negative pressure wound therapy system when used by a member in the home setting

NoncoveredHCPCSNot Covered

A9270

Noncovered item or service

NPWT wound surface area

Up to thresholdTotal wound surface area less than or equal to 50 square centimeters

Above thresholdTotal wound surface area greater than 50 square centimeters

Procedure-code distinctionCodes 97605 and 97607 apply to wounds at or below 50 square centimeters; codes 97606 and 97608 apply to wounds greater than 50 square centimeters

Therapeutic trial duration

Initial trialOne month

ContinuationUp to three additional months, with requests submitted before each subsequent month beginning on the 31st day

Provider Submission and Authorization Actions

Prior Authorization

Initial and Continuation Preauthorization Required

Preauthorization is required for the initial one-month therapeutic trial and for each subsequent month, beginning on day 31 (month 2), for up to three additional months—a maximum total of four months.

Submit the initial request before therapy begins.
Submit continuation requests before each subsequent month of treatment.

Denial Risk

Home-Use Disposable NPWT Without Home Health

Disposable NPWT systems are not eligible for coverage as DME when used by the member at home without a home health plan. They may be eligible when provided as part of a home health plan or in a physician's office.

Apply the appropriate setting and billing requirements for home health or physician-office services.

Therapy Background

Negative pressure wound therapy (NPWT), also called vacuum-assisted closure, uses intermittent or continuous subatmospheric pressure delivered through tubing to a specialized wound dressing. It supports treatment of acute, subacute, and chronic wounds by helping evacuate wound fluid and exudate, reduce edema, and support local vascularity and oxygenation. A typical system includes a pump, tubing, porous foam dressing, and an airtight adhesive dressing; wound-care sets include related supplies and accessories.

Key Definitions

Negative pressure wound therapy (NPWT)

TherapyNegative pressure wound therapy assists in treating acute, subacute, and chronic wounds

PressureIntermittent or continuous subatmospheric pressure

DeliveryAn electrical pump conveys the pressure through connecting tubing to a specialized wound dressing

Vacuum-assisted closure (VAC)

Alternate nameVacuum-assisted closure (VAC)

RelationshipVAC is another name for negative pressure wound therapy

Therapy type

Policy Summary

PayerRegence BlueCross BlueShield

PolicyNegative Pressure Wound Therapy in the Outpatient Setting

Policy CodePolicy M-DME42

Change TypeNo material change

Effective Date04/01/2026

Last ReviewFeb 1, 2026

Next Review Date12/01/2026

Key ActionObtain preauthorization for the initial one-month therapeutic trial and each subsequent month beginning on day 31.

SourceLink

On This Page

Maximum durationFour months total

Wound measurement frequency

Required frequencyAt least monthly

Quantitative measurementsWound length, width or surface area, depth, and amount of drainage

Healing progressDocumentation must indicate progress of healing, with the treating clinician's assessment based on wound measurements in the medical record

Documentation Required

Wound History and Current Management

Submit a complete wound history and current-management record for the wound for which the NPWT pump is billed.

Include prior treatment regimens, when applicable.
Document session length, dressing types, dressing-change frequency, and changes in wound condition.
Include precise measurements, quantity of exudate or drainage, presence of granulation and necrotic tissue, and concurrent wound-therapy measures.

Documentation Required

Regular Wound Evaluation Required

Submit documentation describing regular evaluation and treatment of the beneficiary's wounds.

The record must demonstrate ongoing wound assessment and treatment.

Documentation Required

Monthly Quantitative Wound Measurements

Enter quantitative wound measurements at least monthly and document healing progress. The treating clinician must provide the NPWT supplier with an assessment of wound-healing progress based on measurements documented in the medical record.

Document wound length and width or surface area, depth, and the amount of wound exudate or drainage.
Use the measurements to indicate progress of healing.

Documentation Required

Comparable Month-to-Month Measurements

For month-to-month comparisons, compare like-for-like wound measurements so that the same characteristic is evaluated over time.

Compare depth with depth.
Compare surface area with surface area.

Denial Risk

Incomplete Clinical Documentation Risks Review Outcome

Incomplete or missing wound and treatment documentation may affect the review and decision outcome, including the determination of whether policy criteria are met.

Submit all required wound history, management, evaluation, treatment, measurement, drainage, and healing-progress information.

Denial Risk

Missing Required Preauthorization

Failure to obtain required preauthorization may prevent coverage for the NPWT treatment period. Preauthorization is required for the initial one-month trial and again for treatment beginning on day 31 and for each later month requested, up to the four-month maximum.

Do not assume the initial authorization extends beyond the first month.
Submit continuation authorization before day 31 and before each subsequent month.

The therapy uses subatmospheric pressure to assist treatment of acute, subacute, and chronic wounds

Specialized wound dressing

Foam componentA porous foam dressing covers the entire wound surface

Seal componentAn airtight adhesive dressing seals the wound

FunctionThe dressing contains subatmospheric pressure at the wound site