DraftUnitedHealthcarePolicy CSIS7OH.D

Negative Pressure Wound Therapy (for Ohio Only)

Outpatient use and general coverage of NPWT for Ohio Medicaid members, including statements of proven, unproven, and not medically necessary indications and references to Ohio administrative code and InterQual criteria.

Policy Summary

PayerUnitedHealthcare

PolicyNegative Pressure Wound Therapy (for Ohio Only)

Policy CodePolicy CSIS7OH.D

Change TypeReferences and supporting information updatedprior version archived

Effective DateJul 1, 2025

Next Review Date

Key ActionUse InterQual criteria for outpatient NPWT medical necessity determinations and obtain prior authorization per Ohio Medicaid/DME rules when required.

SourceLink

POLICY UPDATE CHANGES

Supporting Information Updated Clinical Evidence and References sections to reflect the most current information; previous policy version CSISZOH.C archived.

Ohio-onlyPolicy applies to Ohio Medicaid

InterQual referencedMedical necessity criteria source

CPT/HCPCS listedProcedure and supply codes

MultipleSystematic reviews cited

1 archived

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Previous policy archived

Coverage Criteria — Outpatient NPWT

Outpatient NPWT (InterQual-referenced)

Covered when ALL of the following are met:

Outpatient NPWT medical necessity: NPWT is proven and medically necessary in the outpatient setting under circumstances defined by InterQual CP: Durable Medical Equipment; Negative Pressure Wound Therapy (NPWT) Devices.refer to InterQual

Providers must use InterQual criteria for specific clinical eligibility and documentation requirements, and follow applicable Ohio DME rules (Rule 5160-10-01) for general DMEPOS provisions.

Unproven / Not Medically Necessary Indications

The following are stated as unproven and not medically necessary due to insufficient evidence:

Unproven / Not Medically Necessary Uses: Disposable/single-use NPWT systems; NPWT for treating all other indications not specified as proven (including but not limited to pilonidal disease); NPWT systems with instillation of wound solutions.n/a

These uses are listed as unproven and not medically necessary in this policy due to insufficient evidence of efficacy.

Coverage limitations and exclusions for outpatient NPWT reference Ohio Administrative Code provisions. Specifically, consult OAC Rule 5160-10-01 (Durable medical equipment, prostheses, orthoses and supplies — general provisions) and OAC Rule 5160-10-02 (DMEPOS: repair) for applicable limits, exclusions, and repair guidance. These OAC rules should be used to determine any state-specific coverage constraints that supersede or modify the standard benefit guidance in this policy.

Follow applicable federal, state (Ohio Administrative Code), and contractual requirements when making coverage decisions; if there is a conflict, the federal, state (OAC), or contractual terms govern. UnitedHealthcare uses InterQual for primary medical/surgical criteria in administering benefits; when InterQual does not provide applicable criteria, UnitedHealthcare may use its own Medical Policies, Coverage Determination Guidelines, or Utilization Review Guidelines as approved by the Ohio Department of Medicaid Services. Providers should verify and comply with any plan-specific prior authorization and documentation procedures.

The policy identifies several uses and device types as unproven and not medically necessary due to insufficient evidence. These include disposable/single-use NPWT systems, the use of NPWT for indications not otherwise listed (including but not limited to pilonidal disease), and NPWT systems with instillation of wound solutions (NPWTi-d). The literature and systematic reviews cited in the policy describe limited, low-quality, or heterogeneous evidence for these applications and note the need for larger, well-designed studies to establish safety and effectiveness.

Coding and Billing

Applicable CPT CodesCPT

97605	Negative pressure wound therapy, utilizing durable medical equipment (DME), including topical application(s), wound assessment; and instruction(s) for ongoing care, per session; total wound(s) surface area <= 50 square centimeters.
97606	Negative pressure wound therapy, utilizing durable medical equipment (DME), including topical application(s), wound assessment; and instruction(s) for ongoing care, per session; total wound(s) surface area > 50 square centimeters.
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 square centimeters.
97608	Negative pressure wound therapy, utilizing disposable, non-durable medical equipment including provision of exudate management collection system, wound(s) surface area > 50 square centimeters.

Applicable HCPCS / Supply 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.

Wound surface area thresholds for CPT

CPT wound surface area ≤ 50 cm²Use CPT 97605 (DME) or 97607 (disposable systems) for total wound surface area less than or equal to 50 square centimeters.

CPT wound surface area > 50 cm²Use CPT 97606 (DME) or 97608 (disposable systems) for total wound surface area greater than 50 square centimeters.

Code selection depends on device typeSelect the 97605/97606 family when NPWT utilizes durable medical equipment; select 97607/97608 when utilizing disposable, non-durable NPWT systems.

Provider Actions & Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization may be required for outpatient NPWT per state or program rules; providers should verify member benefits and obtain any required prior authorization before initiating outpatient NPWT.

Verify member-specific benefits and prior authorization requirements before initiating outpatient NPWT.
Outpatient NPWT medical necessity determinations reference InterQual CP: Durable Medical Equipment; Negative Pressure Wound Therapy.
Providers should check applicable codes (e.g., CPT 97605–97608 and HCPCS K0743–K0746 where applicable) when submitting authorizations and claims.

Documentation Required

Use InterQual as Primary Criteria

UnitedHealthcare uses InterQual criteria as the primary source for medical necessity determinations for NPWT. If InterQual does not have applicable criteria, UnitedHealthcare may apply its own Medical Policies, Coverage Determination Guidelines, or Utilization Review Guidelines that have been approved by the Ohio Department of Medicaid Services. Providers should apply InterQual first and document how fallback criteria were used when InterQual was not applicable.

Background

Negative pressure wound therapy (NPWT) is a therapeutic dressing system that applies continuous or intermittent subatmospheric pressure to a wound surface using dressings, suction pump, tubing, and a collection chamber. The physiologic rationale includes removal of exudate, reduction of bacterial contamination, reduction of edema, approximation of wound edges, increased local blood flow, and promotion of granulation tissue—making NPWT an adjunctive treatment for wounds not responding to conventional measures such as debridement, pressure relief, and infection control. Outpatient coverage determinations for NPWT are governed by InterQual criteria, which define the clinical circumstances under which NPWT is considered proven and medically necessary.

Definitions

Negative Pressure Wound Therapy (NPWT)

DefinitionA therapeutic dressing system that applies continuous or intermittent negative pressure to a wound surface using dressings, a suction pump, tubing, and a collection chamber to assist healing.

System componentsIncludes porous wound dressing, occlusive/seal dressing, drainage tubing, suction pump, and collection/exudate chamber.

Function / intended effectsDelivers subatmospheric pressure to remove exudate, reduce bacterial contamination, increase local blood flow, reduce edema, approximate wound edges, and promote granulation tissue.

NPWTi-d (NPWT with instillation) — definition and evidence note

DefinitionNPWTi-d is NPWT combined with solution instillation and a dwell time: wound solution is delivered into the wound, allowed to dwell, then removed by negative pressure cycles.

Evidence summary

Policy Summary

PayerUnitedHealthcare

PolicyNegative Pressure Wound Therapy (for Ohio Only)

Policy CodePolicy CSIS7OH.D

Change TypeReferences and supporting information updatedprior version archived

Effective DateJul 1, 2025

Next Review Date

Key ActionUse InterQual criteria for outpatient NPWT medical necessity determinations and obtain prior authorization per Ohio Medicaid/DME rules when required.

SourceLink

On This Page

Apply InterQual CP: Durable Medical Equipment; Negative Pressure Wound Therapy as the primary criteria for outpatient NPWT.
If InterQual lacks applicable criteria, document use of UnitedHealthcare Medical Policies, Coverage Determination Guidelines, or Utilization Review Guidelines approved by the Ohio Department of Medicaid Services.
Document clinical rationale when using fallback criteria and include any supporting records in the prior authorization request.

Note

Reference Governing Documents

Coverage determinations must follow federal, state (Ohio Administrative Code), and contractual benefit plan requirements. In the event of a conflict between this policy and federal, state (OAC), or contractual requirements, the federal, state (OAC), or contractual requirements govern. Providers must check and follow any specific federal/state/contractual mandates that apply to the member’s plan.

Before applying this policy, verify and document any applicable federal, state (OAC), or contractual benefit plan requirements.
When conflicts exist, follow the governing federal, state (OAC), or contractual requirement rather than this policy.
Ohio providers should reference the Ohio Administrative Code (OAC) and any Ohio Medicaid directives when determining coverage and prior authorization requirements.

Denial Risk

Denial Risk: Unproven Indications and Devices

The following uses of NPWT are considered unproven and not medically necessary; submitting requests for these indications or device types risks denial unless supporting evidence and applicable benefit language are provided: disposable/single‑use NPWT systems; NPWT for pilonidal disease and other non‑listed indications; NPWT systems with instillation.

Disposable/single‑use NPWT systems are considered unproven/not medically necessary.
NPWT for pilonidal disease and other indications not supported by evidence is considered unproven/not medically necessary.
NPWT systems with instillation of wound solutions are considered unproven/not medically necessary.

Documentation Required

Documentation & Coding Requirements

Document medical necessity and coding consistent with InterQual and DME documentation standards. Include wound measurements, wound bed description, prior conservative therapy and dates, frequency of dressing changes, and planned duration of therapy when requesting authorization or submitting claims.

Reference InterQual CP: Durable Medical Equipment; Negative Pressure Wound Therapy for required documentation elements.
Include wound size (surface area), wound type and location, prior treatments and dates, and clinical justification for NPWT.
When billing, reference appropriate CPT codes (97605–97608) or HCPCS codes as applicable and include supporting documentation in the medical record and authorization request.

Systematic reviews and meta-analyses report promising results (higher primary wound closure and lower complication rates) but note limited quality, heterogeneity, and need for larger randomized trials.

Clinical contextStudies include orthoplastic, acute, and traumatic wounds; available evidence is variable in design and quality, limiting definitive recommendations.

NPWTi-d — short label

Short labelNPWTi-d: Negative pressure wound therapy with instillation and dwell time.

AbbreviationNPWTi-d.

Use noteInstillation adds delivery of wound solution plus dwell time to standard NPWT cycles; evidence is limited and heterogeneous.