Anthem Blue Cross Connecticut CG-MED-71 Chronic Wound Care in the Home or Outpatient Setting Form

This document addresses wound care in the home or outpatient setting (for example, an outpatient wound center or wound clinic) for a variety of chronic wounds, such as ulcers related to pressure sores, venous or arterial insufficiency, or neuropathy.

Note: Please see the following related documents for additional information:

• CG-DME-06 Compression Devices for Lymphedema
• CG-DME-16 Pressure Reducing Support Surfaces - Groups 1, 2 & 3
• CG-DME-48 Vacuum Assisted Wound Therapy in the Outpatient Setting
• CG-MED-19 Custodial Care
• CG-MED-23 Home Health
• CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)
• CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
• CG-REHAB-08 Private Duty Nursing in the Home Setting
• MED.00096 Low-Frequency Ultrasound Therapy for Wound Management
• MED.00110 Silver-based Products for Wound and Soft Tissue Applications
• SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Clinical Indications

Medically Necessary:

Note: To be eligible for wound care in the home setting, the individual must be confined to the home as defined in CG-MED-23 Home Health.

Initial care for a chronic wound in the home or outpatient setting is considered medically necessary when:

1. The wound care is prescribed by the attending physician, health care provider practicing within the scope of license, or the primary care physician in coordination with the attending physician as part of a written plan of care; and
2. The wound care is so inherently complex that it can only be safely and effectively performed by or under the general supervision of a licensed medical professional (for example, but not limited to stage III or IV pressure ulcers, non-healing neuropathic ulcers, venous or arterial insufficiency related ulcers, persistent wounds); and
3. A complete, individualized wound care program appropriate to the type of wound being treated, which meets all of the requirements below, has been initiated:
   1. Initial documentation in the individual’s medical record of evaluation, plan of care, wound care, wound characteristics, and wound measurements by a licensed medical professional; and
   2. Application of dressings according to manufacturer guidelines; and
   3. Debridement of necrotic tissue if present; and
   4. Evaluation of and provision for adequate nutritional status; and
   5. Underlying medical conditions (for example, venous insufficiency or diabetes) are being appropriately managed.

Continued care for a chronic wound in the home or outpatient setting is considered medically necessary when:

1. The wound care provided meets all the criteria under initial wound care; and
2. Weekly documentation by a licensed medical professional includes all of the following:
   1. The plan of care; and
   2. Wound care provided; and
   3. Assessment of the wound’s dimensions and characteristics; and
3. The primary care physician, health care provider practicing within the scope of license, or attending physician in coordination with the primary care physician should review the plan of care at least once every 30 days to assess the continued need for wound care in the home or outpatient setting; and
4. Progressive wound healing is demonstrated through measurable changes in wound characteristics and wound measurements taken no more than 30 days apart.

Not Medically Necessary:

Care for a chronic wound in the home or outpatient setting is considered not medically necessary when:

1. The plan of care does not demonstrate the need for skilled intervention performed by or under the general supervision of a licensed medical professional; or
2. Criteria for initial wound care in the home or outpatient setting as defined above have not been met; or
3. Criteria for continuing wound care in the home or outpatient setting as defined above have not been met; or
4. The goals have been achieved per the plan of care; or
5. The wound care is custodial as defined in CG-MED-19 Custodial Care.