Negative Pressure Wound Therapy Form

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Negative Pressure Wound Therapy (NPWT), Vacuum-Assisted Wound Closure (VAC) Medical Policy

Service: Negative Pressure Wound Therapy (NPWT), Vacuum-Assisted Wound Closure (VAC)

PUM: 250-0034-1812

Medical Policy Committee Approval 07/25/2024 Effective Date 08/01/2024 Prior Authorization Needed Yes

Description:

Negative pressure wound therapy (NPWT), also known as vacuum-assisted wound closure (VAC), distributes negative pressure (vacuum suction) across a wound to remove drainage and promote wound healing. A wound dressing (foam or gauze) is placed in the wound bed. This is covered with a clear adhesive dressing that creates a seal and maintains a warm moist environment to facilitate wound healing. Tubing is attached to an opening created in the covering. The tubing is connected to a pump which can be set to apply continuous or intermittent negative pressure of variable levels. A collection canister holds the drainage pulled from the wound.

Indications of Coverage:

Negative pressure wound therapy is considered medically necessary when criteria in A. and B. below are met:

A. Wound is any of the following:

1. Diabetic (neuropathic) ulcer as follows: a. Wagner grade 1 ulcer/wound that has not responded to at least 30 days of other conventional wound treatments OR b. Wagner grade 2 or higher ulcer/wound that has not responded within 30 days of wound treatment

2. Stage III or IV pressure ulcer, not improved with conventional wound/ulcer treatment of at least 30 days

3. Venous or arterial insufficiency ulcer, not improved with conventional wound/ulcer treatment of at least 30 days

4. Post-sternotomy wound, post-surgical mediastinitis

5. Open dehisced surgical wound

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6. Skin graft, flap or dermal substitute for acute or chronic wound

7. Open fracture (as a bridge to definitive closure when primary closure is not possible after or between debridement’s)

8. Fasciotomy wound

9. Post amputation diabetic wound

   B. The negative pressure wound therapy is part of a comprehensive wound program that consists of all of the following:

10. Appropriate medical management of the causal or contributing medical condition(s) (such as medical and nutritional management for diabetes, lower extremity elevation and compression garments/bandages for venous insufficiency) is in place

11. Nutritional and hydration status have been evaluated and are being managed as appropriate to support optimal wound healing

12. Environmental and positional/pressure concerns (e.g., frequent repositioning, off- loading, properly fitted devices/braces, incontinence management) have been evaluated and addressed as appropriate

13. Smoking status has been evaluated and smoking cessation assistance/resources have been offered as appropriate

14. A comprehensive wound assessment is completed and documented weekly by a licensed medical professional.

    If indications/criteria in letters A. and B. above are met, the negative pressure wound therapy pump (vac) rental and negative pressure wound therapy supplies may be approved for 30 days.
    Continued use beyond 30 days will require submission of request for extension (every 30 days) which must include updated wound assessment documentation for continued medical necessity review by the Health Plan Medical Director.

    C. To extend authorization of the negative pressure wound therapy pump rental and negative pressure wound therapy supplies, criteria in letters A. and B. must be met and wound assessment documentation must demonstrate progressive wound improvement/healing.

    Limitations of Coverage:

    A. Review contract and endorsements for exclusions and prior authorization or benefit requirements.

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B. If used for a condition/diagnosis other than is listed in the Indications of Coverage, it will be denied as experimental, investigational, and unproven to affect health outcomes.

C. If used for a condition/diagnosis that is listed in the Indications of Coverage; but the criteria are not met, it will be denied as not medically necessary.

D. All of the following will be denied as experimental, investigational, and unproven to affect health outcomes:

1. Single-use, disposable, non-powered, or mechanical negative pressure wound therapy devices (including, but not limited to PICO, SNap, UNO)
2. Negative pressure wound therapy with instillation (NPWTi)
3. ABTHERA® Open Abdomen Negative Pressure Therapy System

4. WoundVision Scout®

   E. Negative pressure wound therapy will be denied as experimental, investigational, and unproven to affect health outcomes for treatment of any of the following:

5. Pilonidal disease/cyst/sinus
6. Partial-thickness burn
7. Infected bypass graft on lower extremity
8. Necrotizing fasciitis
9. Esophageal perforation or leak
10. Prevention of surgical site infection
11. Used prophylactically after surgery

12. When used in conjunction with hyperbaric oxygen therapy or with bioengineered skin substitutes

    F. Negative pressure wound therapy will be denied as not medically necessary when any of the following are present:

13. Malignancy/cancer present in the wound
14. Untreated soft tissue infection or osteomyelitis near the wound
15. Necrotic tissue with eschar in the wound
16. Fistula to an organ or body cavity near the wound
17. Exposed vital structures including nerves, anastomotic site, vasculature, or organ(s)
18. Uniform granulation tissue has been formed
19. Closed, clean (non-infected) incisions
20. Cesarean section (non-infected)
21. For closed surgical incisions following total joint arthroplasty. G. More than one negative pressure wound therapy pump billed per individual for the same dates of service or time span is considered not medically necessary as bridging of the

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tubing from each wound can typically be performed to enable use of only one pump (vac) for multiple wounds.

H. Payment of rental charges exceeding the purchase price of these devices is a limitation of many health plans.

Documentation Required:

• Documentation of the wound program components (as listed in Indications of Coverage, letter B.) • Wound assessment notes • Health care provider order for negative pressure wound therapy pump and supplies.

Disclaimer: This policy is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this policy. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical policy in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

Medical policies are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical policy and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com.

Policy Review History:

Implemented 01/01/20, 04/01/21, 11/01/21, 03/01/23, 09/01/23, 08/01/24 Medical Policy Committee Approval 09/27/19, 10/30/20, 10/28/21, 10/27/22, 08/31/23, 07/25/24 Reviewed

10/30/2020, 10/28/21, 10/27/22, 08/31/23, 07/25/24 Developed 09/27/19

Approved by the Medical Director