CurrentUnitedHealthcarePolicy CS157LA.C

Negative Pressure Wound Therapy (for Louisiana Only)

UnitedHealthcare Community Plan medical policy (Louisiana only) governing outpatient use of negative pressure wound therapy (NPWT) between August 1, 2025 and March 31, 2026, including indication-specific medical necessity criteria, contraindications, discontinuation criteria, definitions, clinical evidence summary, and applicable procedure/supply codes. The policy notes retired status effective April 1, 2026.

Policy Summary

PayerUnitedHealthcare

PolicyNegative Pressure Wound Therapy (for Louisiana Only)

Policy CodePolicy CS157LA.C

Change TypeRetirement and clinical revisions (contraindications updated)

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionProvider must document evaluation, care, wound measurements, prior use of moist dressings, debridement if present, nutritional evaluation, indication for NPWT, and that wound failed conventional treatment after 30 days.

POLICY UPDATE CHANGES

Policy retired effective April 1, 2026 (header states 'Retired April 1, 2026').

Revised list of contraindications to NPWT on 08/01/2025: added 'anticoagulation therapy' and replaced 'uncontrolled soft tissue infection or osteomyelitis within vicinity of wound' with 'uncontrolled soft tissue infection or untreated osteomyelitis within vicinity of wound'.

Retired policy for Louisiana plan membership effective 04/01/2026.

FDA information included for informational purposes only; FDA approval alone is not a basis for coverage.

7Listed proven indications (distinct)

Coverage Summary

UnitedHealthcare Community Plan medical policy (Louisiana only) governing outpatient use of Negative Pressure Wound Therapy (NPWT) between 2025-08-01 and 2026-03-31. The policy defines NPWT, its intended physiologic effects (removal of exudate, reduction of bacterial contamination, increased local blood flow, edema reduction, wound edge approximation, and stimulation of granulation tissue), and restricts outpatient NPWT to specific proven indications only after a documented complete wound therapy program has been tried or considered and ruled out.

This policy was retired effective 2026-04-01; the Louisiana plan membership was disenrolled on that date. Providers should note the effective coverage period stated in the policy and the retirement note when referencing plan-specific coverage decisions.

Key thresholds and quick facts

Conventional treatment trial duration30 days

Compression therapy duration for venous ulcers>= 30 days

Wound depth threshold for discontinuation<= 1 mm

Number of proven indications listed7

Number of contraindications listed5

Overall recommendation strengthWeak positive

Medical-Necessity Criteria

General Precondition (Complete Wound Therapy Program)

A complete wound therapy program, meeting the following criteria, must have been tried or considered and ruled out prior to initiation of NPWT:

ALL of the following

Documentation of evaluation, care, and wound measurements.
Application of dressings to maintain a moist wound environment.
Debridement of necrotic tissue, if present.
Evaluation of and provision for adequate nutritional status.

Evidence Summary & Recommendation Strength

The clinical evidence for NPWT is mixed and of variable quality across wound types. The policy acknowledges existence of Level 1 and Level 2 studies but notes many are moderate or low quality and that inconsistencies across studies are generally explainable.

Randomized and comparative studies exist (for example, multicenter RCTs comparing NPWT systems and multiple RCTs/meta-analyses for diabetic foot ulcers, pressure injuries, open fractures, and surgical wounds), and systematic reviews/meta-analyses have reported both positive and uncertain findings depending on indication and study quality.

Evidence for NPWT with instillation (NPWTi-d) includes multiple systematic reviews and meta-analyses showing promising results (higher primary wound closure, fewer complications) but overall limited by heterogeneous, generally lower-quality studies and lack of large high-quality RCTs.

For pilonidal disease, recent RCT evidence (Ensor et al., 2024) and reviews conclude current evidence is very low quality and do not support NPWT to prevent surgical wound dehiscence; further well-designed studies are needed.

Overall the policy issues a weak positive recommendation: some indications are listed as proven/medically necessary when specific preconditions and indication-specific criteria are met, while other uses (including pilonidal disease, disposable single-use systems, and NPWTi-d in some settings) are characterized as unproven or requiring further evidence. Detailed society guidance summaries and specific recommendation language are rendered in the next block.

IWGDF: Consider the use of NPWT to reduce wound size, in addition to best standard of care, in patients with diabetes and a post-operative (surgical) wound on the foot. (GRADE Strength of recommendation: Weak; Quality of evidence: Low).

IWGDF: We suggest not using NPWT in preference to best standard of care in non-surgical diabetic foot ulcers. (GRADE Strength of recommendation: Weak; Quality of evidence: Low).

Coding

CPT codes for NPWT services (for reference)CPT

97605	Negative pressure wound therapy, utilizing durable medical equipment (DME), per session; total wound(s) surface area <= 50 sq cm
97606	Negative pressure wound therapy, utilizing durable medical equipment (DME), per session; total wound(s) surface area > 50 sq cm
97607	Negative pressure wound therapy, utilizing disposable, non-durable medical equipment including provision of exudate management collection system, per session; total wound(s) surface area <= 50 sq cm
97608	Negative pressure wound therapy, utilizing disposable, non-durable medical equipment including provision of exudate management collection system, per session; total wound(s) surface area > 50 sq cm

HCPCS / DME / supply codesHCPCS|DME

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
K0743-K0746	Suction pumps and dressing codes that apply to devices other than NPWT (coding clarification noted)

State fee schedule notemixed

*	Codes labeled with an asterisk (*) are not on the State of Louisiana Medicaid Fee Schedule and therefore may not be covered by the State of Louisiana Medicaid Program

Informational - FDA product code referencemixed

OMP	FDA product code for NPWT systems (reference link provided; informational only)

Provider Actions / Prior Authorization & Documentation

Documentation Required

Document complete wound therapy program

Document a complete wound therapy program before initiating NPWT. Required documentation elements include clinical evaluation, wound measurements, use of moist dressings, debridement if necrotic tissue is present, nutritional evaluation/provision, the provider's documented indication for NPWT, and documentation that the open wound has not responded to conventional treatment after 30 days.

Documentation of evaluation, care, and wound measurements
Application of dressings to maintain a moist wound environment
Debridement of necrotic tissue, if present
Evaluation of and provision for adequate nutritional status
Provider documentation of indication for NPWT
Documentation that the open wound has not responded to conventional treatment after 30 days

Definitions

Gustilo Grade III Fracture: An open fracture with extensive soft-tissue damage or an open segmental fracture. Subtypes IIIA, IIIB, IIIC are defined by coverage, soft-tissue loss, and arterial injury.

NPIAP Stage III/IV: NPIAP Stage III is full-thickness skin loss with visible fat and granulation tissue; Stage IV is full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone.

NPWTi-d: Negative pressure wound therapy with instillation and dwell time — NPWT combined with periodic instillation of solutions into the wound with a dwell time; systematic reviews/meta-analyses show promising signals (higher primary closure and lower complication rates) but are limited by heterogeneous, lower-quality evidence and lack of high-quality RCTs.

PICO: A single-use negative pressure wound dressing system referenced in NICE guidance and other literature; cited evidence supports consideration in high-risk closed surgical incisions but notes heterogeneity and limitations in available studies.

Revision History

2025-08-01policy_effective_period

Policy effective period established from August 1, 2025 through March 31, 2026 (Effective Date: August 1, 2025 - March 31, 2026).

2026-04-01retirementLatest

Policy retired effective April 1, 2026; Louisiana plan membership disenrolled on April 1, 2026.

2025-08-01material_revision

Contraindications revised (08/01/2025): added 'anticoagulation therapy' and changed wording from 'uncontrolled soft tissue infection or osteomyelitis within vicinity of wound' to 'uncontrolled soft tissue infection or untreated osteomyelitis within vicinity of wound' (marked material).

Policy Summary

PayerUnitedHealthcare

PolicyNegative Pressure Wound Therapy (for Louisiana Only)

Policy CodePolicy CS157LA.C

Change TypeRetirement and clinical revisions (contraindications updated)

Effective DateAug 1, 2025

Next Review DateN/A

On This Page

Indication-Specific Medical Necessity

NPWT in an outpatient setting or upon discharge from an inpatient setting is proven and medically necessary for treating individuals who have undergone a complete wound therapy program and meet ONE of the following indication-specific criteria:

ONE of the following indications

Pressure ulcer (Stage III or IV)
- Complete wound therapy program, as outlined above.
- Appropriate turning and positioning.
- Use of a pressure-reducing support surface.
- Moisture and incontinence management.
Neuropathic ulcer (e.g., diabetic ulcer)
- Complete wound therapy program, as outlined above.
- Comprehensive diabetic management program.
- Reduction in pressure on ulcer (e.g., off-loading).
Venous insufficiency ulcer
- Complete wound therapy program, as outlined above.
- Compression bandages and/or garments have been used consistently.
  Compression must have been used for at least 30 days.
- Leg elevation and ambulation.
Open surgical wound
- Post-operative dehiscence (separation of a previously closed surgical incision) with documentation of a complete wound therapy program, as outlined above.
- Open, non-healing amputation site in diabetics.
- Post-sternotomy infection (mediastinitis).
- Delayed healing or non-healing of skin graft likely due to irregularly contoured or inadequate blood flow of the graft bed.
High-risk open fracture
- Gustilo Grade III open fracture (III A, B, or C).

Indication-Specific Medical Necessity

Unproven / Not Medically Necessary Indications

The following indications and devices are unproven and NOT medically necessary due to insufficient evidence of efficacy:

ANY of the following

Closed surgical incisions.
Pilonidal disease.
Disposable/single-use NPWT systems.
NPWT systems with instillation of wound solutions (NPWTi-d).
All other indications not specifically listed as medically necessary.

Unproven / Not Medically Necessary Indications

Contraindications

NPWT is contraindicated when any of the following are present:

ANY of the following

Active bleeding or exposed vasculature in the wound.
Anticoagulation therapy.
Eschar or necrotic tissue present in the wound.
Exposed bone, nerves, or organs in the vicinity of the wound.
Malignancy present in the wound.
Uncontrolled soft tissue infection or untreated osteomyelitis within the vicinity of the wound.
Presence of an open fistula to body organs or cavities within the vicinity of the wound.

Contraindications

Discontinuation Criteria

NPWT should be discontinued when any of the following criteria are present:

ANY of the following

Documentation of weekly assessment by the provider indicates failure of progressive wound healing (wound is not diminishing in size — either surface area or depth — within 30 days).
Assessments should document wound dimensions and characteristics.
Depth of the wound is 1 mm or less.
Uniform granulation tissue has been obtained.

Discontinuation Criteria

Citation	Takeaway
Kirsner et al. (2019)	Multicenter RCT: single-use NPWT met noninferiority and showed statistical superiority versus traditional NPWT for wound progression and faster closure (limitations: small size, short follow-up; compared NPWT systems, not NPWT vs standard care).
Cochrane (pressure ulcers) / Shi et al. (2023)	Systematic review: very-low certainty evidence; efficacy and safety of NPWT for pressure ulcers are uncertain; further high-quality research needed.
Ensor et al. RCT (pilonidal disease, 2024)	Randomized trial (n=50): no difference in wound dehiscence, healing time, analgesia, or return to activities between NPWT and conventional dressings; NPWT not recommended to prevent surgical wound dehiscence.
De Pellegrin et al. (2023) meta-analysis	Meta-analysis (13 studies, n=871): NPWT with instillation (NPWTi-d) showed higher primary wound closure and lower complication rates versus NPWT or standard care; limited by heterogeneity and study quality; RCTs needed.
Gabriel et al. (2021) / Kanapathy et al. (2020)	Systematic reviews/meta-analyses of NPWTi-d (13 studies): suggest benefits (reduced debridements, faster readiness for closure, reduced bioburden, high pooled healing proportions) but evidence is low-quality and heterogeneous.
Strugala & Martin (2017) meta-analysis	Meta-analysis (16 studies, n=1863): prophylactic single-use NPWT (PICO) associated with reduced SSIs, wound dehiscence, and hospital LOS; limitations include heterogeneous study populations and inclusion of non-clean incisions.

Documentation Required

Indication-specific documentation

Document indication-specific elements in the medical record. Ensure the record includes the specific items required for the patient’s wound type (examples below).

Pressure ulcer (Stage III or IV): complete wound therapy program, appropriate turning/positioning, use of a pressure-reducing support surface, moisture and incontinence management
Neuropathic (diabetic) ulcer: complete wound therapy program, comprehensive diabetes management, documentation of pressure-reduction measures for the ulcer
Venous insufficiency ulcer: complete wound therapy program, consistent use of compression bandages/garments for at least 30 days, leg elevation and ambulation
Open surgical wound: post-operative dehiscence with complete wound therapy program; open non-healing amputation site in diabetics; post-sternotomy infection (mediastinitis); delayed or non-healing skin graft due to contour or inadequate blood flow
High-risk open fracture (Gustilo Grade III): documentation of fracture grade and complete wound therapy program

Documentation Required

Weekly wound assessment

Perform and document weekly wound assessments while the patient is receiving NPWT. Record wound dimensions and characteristics and monitor for stopping criteria.

Weekly documentation of wound dimensions (surface area, depth) and characteristics
Discontinue NPWT when there is failure of progressive healing within 30 days, wound depth is ≤ 1 mm, or uniform granulation tissue has been obtained

Documentation Required

Reference federal/state/contract benefits

Federal, state, and contract benefits may govern coverage for specific members and can override this policy. Verify member-specific benefit language and state program rules when determining coverage and documenting medically necessary care.

Prior Authorization

Policy changes & plan-specific effects

Policy revisions and plan-specific effects may affect coverage, prior authorization, and effective dates. Confirm plan-specific rules and prior authorization requirements before initiating therapy.

08/01/2025: Policy effective date for Louisiana — contraindication update included in this effective period
04/01/2026: This policy was retired for Louisiana effective April 1, 2026; verify whether the member’s plan continued coverage or transitioned to another policy
Check plan-specific prior authorization rules, effective dates, and any state-mandated exceptions that may modify application of this policy