CurrentUnitedHealthcarePolicy CS157KS.02

Negative Pressure Wound Therapy (for Kansas Only)

State-specific UnitedHealthcare medical policy that governs coverage and documentation expectations for negative pressure wound therapy (NPWT) for members in Kansas, referencing Kansas Medical Assistance Program clinical criteria and listing applicable CPT/HCPCS codes and device codes.

Policy Summary

PayerUnitedHealthcare

PolicyNegative Pressure Wound Therapy (for Kansas Only)

Policy CodePolicy CS157KS.02

Change TypeDocumentation expectations added; references updated

Effective DateJune 1, 2026

Next Review Date

Key ActionDocument relevant medical history, physical examination, and pertinent diagnostic test results that fully support medical necessity for NPWT and make documentation legible and available upon request.

POLICY UPDATE CHANGES

Expanded Medical Records Documentation Used for Reviews section to add detailed documentation expectations for medical necessity.

Updated References section to reflect current information and archived previous policy version CS157KS.01.

4Listed NPWT CPT/HCPCS codes

Kansas onlyGeographic scope

Coverage Summary

Policy Number: CS157KS.02. Subject: Negative Pressure Wound Therapy (NPWT) - Kansas only. Status: CURRENT. This is a state-specific UnitedHealthcare medical policy that applies only to members in Kansas and interprets coverage for NPWT. Coverage decisions defer to the Kansas Medical Assistance Program clinical criteria; benefit determinations are governed by applicable federal, state, or contractual requirements. The policy lists applicable CPT and HCPCS codes and documents expectations for medical records and documentation when assessing medical necessity.

Medical-Necessity Criteria

Coverage Rationale / Clinical Criteria Pointer

Coverage is determined by the Kansas Medical Assistance Program: Professional Durable Medical Equipment Fee-For-Service Provider Manual; medical necessity must be supported in the medical record.

ALL of the following

Kansas member: Patient is a Kansas member (policy applies only to the state of Kansas).
Meet Kansas Medical Assistance Program criteria: Medical necessity for NPWT must meet clinical coverage criteria as specified in the Kansas Medical Assistance Program: Professional Durable Medical Equipment Fee-For-Service Provider Manual.
Documentation requirements: Medical records documentation must fully support medical necessity and may include relevant medical history, physical exam, and diagnostic test results; documentation must be legible, maintained in the record, and available upon request.

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Coding

NPWT CPT codes (per-session)CPT

97605	Negative pressure wound therapy, utilizing DME, including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area ≤ 50 cm²
97606	Negative pressure wound therapy, utilizing DME, including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area > 50 cm²
97607	Negative pressure wound therapy, 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 ≤ 50 cm²
97608	Negative pressure wound therapy, 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 > 50 cm²

NPWT HCPCS / supply and device codesHCPCS

A6550	Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories
A9272	Wound suction, disposable, includes dressing, all accessories and components, any type, each
E2402	Negative pressure wound therapy electrical pump, stationary or portable

Suction pump and dressing codes (not NPWT devices)HCPCS

K0743-K0746

Suction pumps and dressing codes apply to devices other than negative pressure wound therapy

Provider Actions

Documentation Required

Support medical necessity in the medical record

Document relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures that fully support the medical necessity for the requested NPWT service. Ensure documentation is legible, maintained in the patient's medical record, and made available upon request.

97605
97606
97607
97608
A6550
A9272
E2402

Prior Authorization

Follow Kansas Medical Assistance Program clinical criteria

Obtain and document that NPWT meets the Kansas Medical Assistance Program: Professional Durable Medical Equipment Fee-For-Service Provider Manual clinical criteria prior to coverage. Note that benefit coverage decisions are determined by federal, state, or contractual requirements and applicable laws.

Background

This document is an interpretive medical policy for UnitedHealthcare standard benefit plans in Kansas and applies only to the state of Kansas. For medical necessity clinical coverage criteria for NPWT, the policy directs users to the Kansas Medical Assistance Program: Professional Durable Medical Equipment Fee-For-Service Provider Manual. Medical records documentation requirements are specified: benefit coverage is determined by federal, state, or contractual requirements; documentation may be required to assess whether the member meets clinical criteria; and the patient record must fully support medical necessity and include relevant medical history, physical examination, and results of pertinent diagnostic tests, be legible, maintained in the record, and available upon request. U.S. Food and Drug Administration information in this policy is provided for informational purposes only and FDA approval alone is not a basis for coverage.

Definitions

NPWTNegative Pressure Wound Therapy

Revision History

06/01/2026material_changeLatest

Expanded Medical Records Documentation Used for Reviews section to add detailed documentation expectations: benefit coverage is determined by federal, state, or contractual requirements; medical records documentation may be required to assess whether the member meets clinical criteria but does not guarantee coverage; the patient's medical record must contain documentation that fully supports medical necessity including, but not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures; documentation must be legible, maintained in the patient's medical record, and made available upon request.

06/01/2026references_updated

Updated References section to reflect the most current information and archived previous policy version CS157KS.01; added reference to Kansas Medical Assistance Program Durable Medical Equipment Fee-for-Service Provider Manual.

Policy Summary

PayerUnitedHealthcare

PolicyNegative Pressure Wound Therapy (for Kansas Only)

Policy CodePolicy CS157KS.02

Change TypeDocumentation expectations added; references updated

Effective DateJune 1, 2026

Next Review Date

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