MP-18 Negative Pressure Wound Therapy Form

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Medical Policy
Negative Pressure Wound Therapy ( NPWT )
Current Effective Date: 10/01/2017
Original Effective Date: 01/20/2014
Next Revision Date: 10/01/2018
Plans: QUEST Integration (Medicaid), AlohaCare Advantage Plus Special Needs Plan (SNP Medicare)

I. Definition

Negative Pressure Wound Therapy (NPWT) is defined as the application of sub‐atmospheric pressure to a wound to remove exudate. NPWT is delivered through an integrated system of a suction pump, separate exudate collection chamber and dressing sets to a qualified wound. In these systems, exudate is removed from the wound site to the collection chamber.
II. Criteria
A. Negative Pressure Wound Therapy (NPWT) pump and supplies are covered for Medicaid members who meet the following criteria:

1. The member has a surgical wound with significant drainage

2. A complete wound therapy program described by the following criteria must have been considered, tried, and found ineffective in order to qualify for NPWT.
   a. The member’s medical record of evaluation, treatment, and wound measurements must have been documented by a licensed healthcare professional, such as a physician, physician’s assistant, registered nurse, licensed practical nurse, or physical therapist with background or training in wound care.
   b. Debridement must have been performed when necrotic tissue is present
   c. Evaluation of and provision for adequate nutritional status must have been performed.
   d. If the following ulcers with drainage occurs in an inpatient setting, appropriate procedures must have been performed before applying NPWT:

   i.
   For Stage III or IV pressure ulcers:
   • The member has been appropriately turned and positioned, and
   • The member has used a group 2 or 3 support surface (see Appendix) for pressure ulcers on the posterior trunk or pelvis,
   • The member’s moisture and incontinence have been appropriately managed ii.
   For neuropathic (for example, diabetic) ulcers:
   • The member has been on a comprehensive diabetic management program, and

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Negative Pressure Wound Therapy ( NPWT )
• Reduction in pressure on a foot ulcer has been accomplished with appropriate modalities iii.
For venous insufficiency ulcers:
• Compression bandages and/or garments have been consistently applied, and  Leg elevation and ambulation have been encouraged
B. Negative Pressure Wound Therapy (NPWT) pump and supplies are covered for SNP Medicare members who meet Local Coverage Determination (LCD) (L33821), https://med.noridianmedicare.com/documents/2230703/7218263/Negative+Pressure+Wound+ Therapy+Pumps+LCD+and+PA/21a6cc9a‐7d71‐4b36‐9445‐6d7585c4eac9
C. Continued application of NPWT by a licensed health professional is covered for up to four months for SNP Medicare and covered for Medicaid when all of the following criteria are met :

1. Directly assess the wound(s) being treated with the NPWT pump and supervise or directly perform the NPWT dressing changes on a regular basis

2. Document changes in the ulcer’s dimensions and characteristics on at least a monthly basis

   III. Guidelines
   A. Prior authorization (PA) is required for initiation and continuation of NPWT. Medical records including the treatment plan and evaluation of the wound must be submitted along with the PA.
   B. The initial PA is covered for a duration of one month for SNP Medicare members and may be covered for more than one month for Medicaid members based on the medical necessity.

   IV. Limitations
   A. Requests for NPWT may be considered not medically necessary for SNP Medicare members with any of the following indications and will be reviewed on a case by case basis.

3. In the judgment of the treating physician, adequate wound healing has occurred to the degree that NPWT may be discontinued.
4. Any measurable degree of wound healing has failed to occur over the prior month. Wound healing is defined as improvement occurring in either surface area (length times width) or depth of the wound.
5. 4 months (including the time NPWT was applied in an inpatient setting prior to discharge to the home) have elapsed using an NPWT pump in the treatment of the most recent wound.
6. Once equipment or supplies are no longer being used for the member, whether or not by the physician’s order.
   B. Necrotic tissue with eschar is present;
   C. Osteomyelitis within the vicinity of the wound occurs when the wound is not concurrently being treated with intent to cure;

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Negative Pressure Wound Therapy ( NPWT )
D. Cancer is present in the wound;
E. An open fistula is present to an organ or body cavity within the vicinity of the wound.
F. Coverage is provided up to a maximum of 15 dressing kits (A6550) per wound per month unless there is documentation that the wound size requires more than one dressing kit for each dressing change.

G. Coverage is provided up to a maximum of 10 canister sets (A7000) per month unless there is documentation evidencing a large volume of drainage (greater than 90 ml of exudate per day).
For high volume exudative wounds, a stationary pump with the largest capacity canister must be used.
H. NPWT pumps (E2402) must be capable of accommodating more than one wound dressing set for multiple wounds on a member. Therefore, more than one E2402 billed per member for the same time period will be denied as not reasonable and necessary.

V. Coding Information

The following medical codes are relevant codes for diagnosis and procedures for negative pressure wound therapy and for informational purposes only. All the medical codes listed in this policy do not constitute or imply benefit coverage or provider reimbursement.
ICD‐10‐CM
Description
E10.40‐E10.49
Type 1 diabetes mellitus with circulatory complications E10.51‐E10.59
Type 1 diabetes mellitus with circulatory complications E11.40‐E11.49
Type 2 diabetes mellitus with neurological complications
E11.51‐E11.59
Type 2 diabetes mellitus with circulatory complications I70.25
Atherosclerosis of native arteries of other extremities with ulceration I70.261‐I70.268
Atherosclerosis of native arteries of extremities with gangrene
I83.001‐I83.008
Varicose veins of unspecified lower extremity with ulcer I83.011‐I83.018
Varicose veins of right lower extremity with ulcer I83.021‐I93.028
Varicose veins of left lower extremity with ulcer L89.013
Pressure ulcer of right elbow, stage III

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Negative Pressure Wound Therapy ( NPWT )
L89.014
Pressure ulcer of right elbow, stage IV
L89.023
Pressure ulcer of left elbow, stage III L89.024
Pressure ulcer of left elbow, stage IV
L89.113
Pressure ulcer of right upper back, stage III L89.114
Pressure ulcer of right upper back, stage IV
L89.123
Pressure ulcer of left upper back, stage III L89.124
Pressure ulcer of left upper back, stage IV L89.133
Pressure ulcer of right lower back, stage III L89.134
Pressure ulcer of right lower back, stage IV L89.143
Pressure ulcer of left lower back, stage III L89.144
Pressure ulcer of left lower back, stage IV L89.153
Pressure ulcer of sacral region, stage III L89.154
Pressure ulcer of sacral region, stage IV L89.213
Pressure ulcer of right hip, stage III L89.214
Pressure ulcer of right hip, stage IV
L89.223
Pressure ulcer of left hip, stage III L89.224
Pressure ulcer of left hip, stage IV
L89.313
Pressure ulcer of right buttock, stage III L89.314
Pressure ulcer of right buttock, stage IV L89.323
Pressure ulcer of left buttock, stage III L89.324
Pressure ulcer of left buttock, stage IV L89.43
Pressure ulcer of contiguous site of back, buttock and hip, stage III
L89.44
Pressure ulcer of contiguous site of back, buttock and hip, stage IV
L89.513
Pressure ulcer of right ankle, stage III

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Negative Pressure Wound Therapy ( NPWT )
L89.514
Pressure ulcer of right ankle, stage IV L89.523
Pressure ulcer of left ankle, stage III L89.524
Pressure ulcer of left ankle, stage IV L89.613
Pressure ulcer of right heel, stage III L89.614
Pressure ulcer of right heel, stage IV L89.623
Pressure ulcer of left heel, stage III L89.624
Pressure ulcer of left heel, stage IV L89.813
Pressure ulcer of head, stage III L89.814
Pressure ulcer of head, stage IV L89.893
Pressure ulcer of other site, stage III
L89.894
Pressure ulcer of other site, stage IV T81.31XA
Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter
T81.32XA
Disruption of internal operation (surgical) wound, not elsewhere classified, initial encounter
T81.4XXA
Infection following a procedure, initial encounter T81.89XA
Other complications of procedures, not elsewhere classified, initial encounter

CPT
Description
97605
Negative pressure wound therapy (eg, vacuum assisted drainage collection), 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 centimeters
97606

Negative pressure wound therapy (eg, vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters

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Negative Pressure Wound Therapy ( NPWT )
HCPCS
Description
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

References/Resources

Document Name
Effective
Source
Date

Negative Pressure Wound
5/25/2017
Noridian Healthcare Solutions

Therapy (L33821)
https://med.noridianmedicare.com/documents/2230703/ 7218263/Negative+Pressure+Wound+Therapy+Pumps+LC D+and+PA/21a6cc9a‐7d71‐4b36‐9445‐6d7585c4eac9

Negative Pressure Wound
10/01/2015 Noridian Healthcare Solutions

Therapy (L33821)
https://med.noridianmedicare.com/documents/2230703/ 7218263/Negative+Pressure+Wound+Therapy+Pumps+LC D+and+PA

LCD for Negative Pressure
11/01/2013 Noridian Durable Medical Equipment

Wound Therapy
https://www.noridianmedicare.com/dme/coverage/docs/

LCD
lcds/currentlcds/negativepressurewoundtherapy.htm

L11489

Pressure Reducing Support
11/01/2013 Noridian Durable Medical Equipment
Surfaces‐Group 2 & 3 https://www.noridianmedicare.com/dme/coverage/docs/l LCD L11578 cds/currentlcds/pressurereducingsupportsurfaces_‐

LCD L11579
group2.htm
https://www.noridianmedicare.com/dme/coverage/docs/l cds/currentlcds/pressurereducingsupportsurfaces_g roup3.htm
Negative Pressure Wound 08/08/2012
UpToDate: http://www.uptodate.com/contents/negativeTherapy
pressure‐wound‐therapy

Negative Pressure Wound
2010
FDA:
Therapy: Use with care
http://www.fda.gov/MedicalDevices/Safety/AlertsandNoti ces/T ipsandArticlesonDeviceSafety/ucm225038.htm An overview of negative
2009 Capobianco CM, Zgonis T Clin Podiatr Med Surg

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Medical Policy
Negative Pressure Wound Therapy ( NPWT )
pressure wound therapy for the lower extremity.

The economic benefits of
02/09/2012 Dowsett C, Davis L, Henderson V, Searle R. Clinical Case

negative pressure wound
Reports.
therapy in community‐based
http://onlinelibrary.wiley.com/doi/10.1111/j.1742wound care in the NHS.
481X.2011.00913.x/abstract

Negative Pressure Wound
03/01/2012 UHA

Therapy Policy
https://uhahealth.com/uploads/forms/form_dme_Negativ e‐Pressure‐Wound.pdf

Negative Pressure Wound
12/06/2012 WellCare

Therapy Policy
https://www.wellcare.com/WCAssets/corporate/assets/cc g/ccgnegativepressurewoundtherapy122012.pdf

Negative Pressure Wound
06/25/2013 Aetna

Therapy Policy
http://www.aetna.com/cpb/medical/data/300_399/0334. html

Negative Pressure Wound
03/01/2013 HMSA

Therapy Policy
http://www.hmsa.com/PORTAL/PROVIDER/MM.01.005_N egativePressureWoundTherapy(NPWT)_030113.pdf

Review/Revision History
9/1/2017, updated the criteria and references.
10/01/2018 , Retired