Anthem Blue Cross Connecticut CG-DME-48 Vacuum Assisted Wound Therapy in the Outpatient Setting Form

This document addresses the use of vacuum assisted wound therapy (also known as negative pressure wound therapy or NPWT) in the outpatient setting for a variety of wounds, including ulcers related to pressure sores, venous or arterial insufficiency or neuropathy. These devices have several attributes that are used to differentiate them from each other, including being stationary vs. portable, if they are operated electrically vs. mechanically, and if they are reusable or disposable. Each device has some combination of these attributes.

Note: For additional information regarding wound care, please refer to:

• CG-MED-71 Chronic Wound Care in the Home or Outpatient Setting
• SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Clinical Indications

Medically Necessary:

Vacuum assisted wound therapy is considered medically necessary when the individual meets all of the criteria (A, B, and C) below:

1. A complete wound care program, which meets ALL of the requirements below, has been tried:
   1. Documentation in the individual’s medical record of evaluation, care, and wound measurements by a licensed medical professional; and
   2. Application of dressings to maintain a moist environment; and
   3. Debridement of necrotic tissue if present; and
   4. Evaluation of and provision for adequate nutritional status; and
   5. Underlying medical conditions (e.g., diabetes, venous insufficiency) are being appropriately managed; and
2. An eligible condition is documented (individual must meet one or more of the following): 
   1. Stage III or IV pressure ulcers (see key terms below) at initiation of vacuum assisted wound therapy, in individuals who meet ALL of the following:
      1. The individual has been appropriately turned and positioned; and
      2. The individual has used a group 2 or 3 support surface for pressure ulcers on the posterior trunk or pelvis (no special support surface is required for ulcers not located on the trunk or pelvis); and
      3. The individual’s moisture and incontinence have been appropriately managed; or
   2. Neuropathic ulcers in individuals who meet BOTH of the following:
      1. The individual has been on a comprehensive diabetic management program; and
      2. Reduction in pressure on a foot ulcer has been accomplished with appropriate modalities; or
   3. Ulcers related to venous or arterial insufficiency, in individuals who meet ALL of the following:
      1. Compression bandages and/or garments have been consistently applied; and
      2. Reduction in pressure on a foot ulcer has been accomplished with appropriate modalities; and
      3. For initiation of therapy in the home setting, presence of the ulcer for at least 30 days; or
   4. Dehisced wounds or wound with exposed hardware or bone; or
   5. Post sternotomy wound infection or mediastinitis; or
   6. Complications of a surgically created wound where accelerated granulation therapy is necessary and cannot be achieved by other available topical wound treatment; and
3. The wound to be treated is free from all of the following absolute contraindications to vacuum assisted wound therapy:
   1. Exposed anastomotic site; or
   2. Exposed nerves; or
   3. Exposed organs; or
   4. Exposed vasculature; or
   5. Malignancy in the wound; or
   6. Necrotic tissue with eschar present; or
   7. Non-enteric and unexplored fistulas; or
   8. Untreated osteomyelitis.

Continued use of vacuum assisted wound therapy is considered medically necessary when:

1. Weekly assessment of the wound’s dimensions and characteristics by a licensed health care professional is documented; and
2. Progressive wound healing is demonstrated.

Not Medically Necessary:

Continued use of vacuum assisted wound therapy is considered not medically necessary when the continuation of treatment criteria above have not been met.

Vacuum assisted wound therapy is considered not medically necessary for all other applications not meeting the medical necessity criteria above, including for routine prophylactic use in the postoperative setting.