543 Form

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Medical Policy
Negative Pressure Wound Therapy in the Outpatient Setting Table of Contents
• Policy: Commercial • Description • Information Pertaining to All Policies
• Authorization Information • Policy History • Endnotes • Coding Information
• References

Policy Number: 543 BCBSA Reference Number: N/A

Related Policies 543 • Orthopedic Applications of Platelet-Rich Plasma, #737 • Electrostimulation and Electromagnetic Therapy for Treating Wounds, #655 • Noncontact Ultrasound Treatment for Wounds, #657 • Bio-Engineered Skin and Soft Tissue Substitutes, #663 Policy1
Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

Documentation by a licensed medical professional in the individual's medical record of all wound evaluation and care (including wound measurements) is good clinical practice and is a prerequisite for the use of wound healing measures covered by this policy.

Initiation of an electrically powered negative pressure wound therapy (NPWT) system is considered MEDICALLY NECESSARY when the individual meets ALL of the criteria (1, 2, 3, 4 and 5) below:1

1. If adequate wound healing is not occurring despite appropriate application of all the measures below:
   • Application of dressings to maintain a moist environment; AND • Debridement of necrotic tissue if present; AND • Evaluation of and provision for adequate nutritional status; AND • Underlying medical conditions (e.g., diabetes, venous insufficiency) are being appropriately managed;

   AND

   • An eligible condition is documented (individual must meet one or more of the following):
   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: o The individual has been appropriately turned and positioned; AND

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o If pressure ulcers are located on the posterior trunk or pelvis, the individual has used a group 2 or 3 support surface. (No special support surface is required for ulcers not located on the trunk or pelvis); AND o The individual's moisture and incontinence have been appropriately managed

OR

• Diabetic neuropathic ulcers in individuals who meet BOTH of the following: o The individual has been on a comprehensive diabetic management program; AND o Reduction in pressure on a foot ulcer has been accomplished with appropriate modalities;

OR

• Ulcers related to venous or arterial insufficiency, in individuals who meet ALL of the following: o Compression bandages and/or garments have been consistently applied; AND o Reduction in pressure on a foot ulcer has been accomplished with appropriate modalities; AND o For initiation of therapy in the home setting, the ulcer must have been present for at least 30 days;

OR

• Dehisced wounds or wound with exposed hardware or bone;

OR

• Post sternotomy wound infection or mediastinitis;

OR

• Complications of a surgically created wound where accelerated granulation therapy is necessary and cannot be achieved by other available topical wound treatment;

OR

• Skin graft success is questionable and hospital admissions will be avoided (coverage is provided for 5 days);

OR

• Wounds with massive exudate/transudate where normal dressings fill up quickly and macerate the wound

AND

2. The wound to be treated is free from all of the following absolute contraindications to vacuum assisted wound therapy: • Exposed anastomotic site; OR • Exposed nerves; OR • Exposed organs; OR • Exposed vasculature; OR • Malignancy in the wound; OR • Necrotic tissue with eschar present; OR • Non-enteric, unexplored fistulas; OR • Untreated osteomyelitis, OR

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• Macroscopic contamination.

AND

3. The powered negative pressure wound therapy (NPWT) system is being used as an adjunct therapy or as an alternative to surgery,

   AND

4. The medical record documents that the patient is willing and able to comply with using continuous or intermittent V.A.C. application 22 of 24 hours per day.

   Continued use of electrically powered negative pressure wound therapy is considered MEDICALLY NECESSARY when:
   • Weekly assessment of the wound’s dimensions and characteristics by a licensed health care professional is documented; AND • The initial trial has resulted in documented objective improvements in the wound, AND • Documentation of continued progressive wound healing is demonstrated.

   Continued use of electrically powered vacuum assisted wound therapy is considered NOT MEDICALLY NECESSARY when the continuation of treatment criteria above have not been met.

   Electrically powered negative pressure wound therapy is considered INVESTIGATIONAL for all other applications not meeting the medical necessity criteria above, including when any absolute contraindications to negative pressure wound therapy are present.

   NON-electrically powered negative pressure wound therapy (for example, the SNaP™ Wound Care Device) is considered INVESTIGATIONAL.

   Portable, battery powered, single use (disposable) negative pressure wound therapy devices (for example, the PICO™ Single Use Negative Pressure Wound Therapy System or the V.A.C.Via™ Negative Pressure Wound Therapy System) are considered INVESTIGATIONAL for all conditions.

   Prior Authorization Information
   Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
   Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

   Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO
   Prior authorization is not required. CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

   Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

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The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity:

CPT Codes CPT codes:

Code Description 97605 Negative pressure wound therapy (e.g., 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 (e.g., 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 HCPCS Codes HCPCS codes: Code Description A6550 Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories
E2402 Negative pressure wound therapy electrical pump, stationary or portable

ICD-10 Diagnosis Codes ICD-10-CM Diagnosis codes: Code Description E08.621 Diabetes mellitus due to underlying condition with foot ulcer E09.621 Drug or chemical induced diabetes mellitus with foot ulcer E10.621 Type 1 diabetes mellitus with foot ulcer E11.621 Type 2 diabetes mellitus with foot ulcer E13.621 Other specified diabetes mellitus with foot ulcer I70.231 Atherosclerosis of native arteries of right leg with ulceration of thigh I70.232 Atherosclerosis of native arteries of right leg with ulceration of calf I70.233 Atherosclerosis of native arteries of right leg with ulceration of ankle I70.234 Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot I70.235 Atherosclerosis of native arteries of right leg with ulceration of other part of foot I70.238 Atherosclerosis of native arteries of right leg with ulceration of other part of lower leg I70.239 Atherosclerosis of native arteries of right leg with ulceration of unspecified site I70.241 Atherosclerosis of native arteries of left leg with ulceration of thigh I70.242 Atherosclerosis of native arteries of left leg with ulceration of calf I70.243 Atherosclerosis of native arteries of left leg with ulceration of ankle I70.244 Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot I70.245 Atherosclerosis of native arteries of left leg with ulceration of other part of foot I70.248 Atherosclerosis of native arteries of left leg with ulceration of other part of lower leg I70.249 Atherosclerosis of native arteries of left leg with ulceration of unspecified site I70.25 Atherosclerosis of native arteries of other extremities with ulceration I83.001 Varicose veins of unspecified lower extremity with ulcer of thigh I83.002 Varicose veins of unspecified lower extremity with ulcer of calf I83.003 Varicose veins of unspecified lower extremity with ulcer of ankle I83.004 Varicose veins of unspecified lower extremity with ulcer of heel and midfoot I83.005 Varicose veins of unspecified lower extremity with ulcer other part of foot I83.008 Varicose veins of unspecified lower extremity with ulcer other part of lower leg I83.009 Varicose veins of unspecified lower extremity with ulcer of unspecified site

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I83.011 Varicose veins of right lower extremity with ulcer of thigh I83.012 Varicose veins of right lower extremity with ulcer of calf I83.013 Varicose veins of right lower extremity with ulcer of ankle I83.014 Varicose veins of right lower extremity with ulcer of heel and midfoot I83.015 Varicose veins of right lower extremity with ulcer other part of foot I83.018 Varicose veins of right lower extremity with ulcer other part of lower leg I83.019 Varicose veins of right lower extremity with ulcer of unspecified site I83.021 Varicose veins of left lower extremity with ulcer of thigh I83.022 Varicose veins of left lower extremity with ulcer of calf I83.023 Varicose veins of left lower extremity with ulcer of ankle I83.024 Varicose veins of left lower extremity with ulcer of heel and midfoot I83.025 Varicose veins of left lower extremity with ulcer other part of foot I83.028 Varicose veins of left lower extremity with ulcer other part of lower leg I83.029 Varicose veins of left lower extremity with ulcer of unspecified site I83.201 Varicose veins of unspecified lower extremity with both ulcer of thigh and inflammation I83.202 Varicose veins of unspecified lower extremity with both ulcer of calf and inflammation I83.203 Varicose veins of unspecified lower extremity with both ulcer of ankle and inflammation I83.204 Varicose veins of unspecified lower extremity with both ulcer of heel and midfoot and inflammation I83.205 Varicose veins of unspecified lower extremity with both ulcer other part of foot and inflammation I83.208 Varicose veins of unspecified lower extremity with both ulcer of other part of lower extremity and inflammation I83.209 Varicose veins of unspecified lower extremity with both ulcer of unspecified site and inflammation I83.211 Varicose veins of right lower extremity with both ulcer of thigh and inflammation I83.212 Varicose veins of right lower extremity with both ulcer of calf and inflammation I83.213 Varicose veins of right lower extremity with both ulcer of ankle and inflammation I83.214 Varicose veins of right lower extremity with both ulcer of heel and midfoot and inflammation I83.215 Varicose veins of right lower extremity with both ulcer other part of foot and inflammation I83.218 Varicose veins of right lower extremity with both ulcer of other part of lower extremity and inflammation I83.219 Varicose veins of right lower extremity with both ulcer of unspecified site and inflammation I83.221 Varicose veins of left lower extremity with both ulcer of thigh and inflammation I83.222 Varicose veins of left lower extremity with both ulcer of calf and inflammation I83.223 Varicose veins of left lower extremity with both ulcer of ankle and inflammation I83.224 Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation I83.225 Varicose veins of left lower extremity with both ulcer other part of foot and inflammation I83.228 Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation I83.229 Varicose veins of left lower extremity with both ulcer of unspecified site and inflammation I87.311 Chronic venous hypertension (idiopathic) with ulcer of right lower extremity I87.312 Chronic venous hypertension (idiopathic) with ulcer of left lower extremity I87.313 Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity I87.319 Chronic venous hypertension (idiopathic) with ulcer of unspecified lower extremity I87.331 Chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity I87.332 Chronic venous hypertension (idiopathic) with ulcer and inflammation of left lower extremity I87.333 Chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity

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I87.339 Chronic venous hypertension (idiopathic) with ulcer and inflammation of unspecified lower extremity L89.003 Pressure ulcer of unspecified elbow, stage 3 L89.004 Pressure ulcer of unspecified elbow, stage 4 L89.013 Pressure ulcer of right elbow, stage 3 L89.014 Pressure ulcer of right elbow, stage 4 L89.023 Pressure ulcer of left elbow, stage 3 L89.024 Pressure ulcer of left elbow, stage 4 L89.103 Pressure ulcer of unspecified part of back, stage 3 L89.104 Pressure ulcer of unspecified part of back, stage 4 L89.113 Pressure ulcer of right upper back, stage 3 L89.114 Pressure ulcer of right upper back, stage 4 L89.123 Pressure ulcer of left upper back, stage 3 L89.124 Pressure ulcer of left upper back, stage 4 L89.133 Pressure ulcer of right lower back, stage 3 L89.134 Pressure ulcer of right lower back, stage 4 L89.143 Pressure ulcer of left lower back, stage 3 L89.144 Pressure ulcer of left lower back, stage 4 L89.153 Pressure ulcer of sacral region, stage 3 L89.154 Pressure ulcer of sacral region, stage 4 L89.203 Pressure ulcer of unspecified hip, stage 3 L89.204 Pressure ulcer of unspecified hip, stage 4 L89.213 Pressure ulcer of right hip, stage 3 L89.214 Pressure ulcer of right hip, stage 4 L89.223 Pressure ulcer of left hip, stage 3 L89.224 Pressure ulcer of left hip, stage 4 L89.303 Pressure ulcer of unspecified buttock, stage 3 L89.304 Pressure ulcer of unspecified buttock, stage 4 L89.313 Pressure ulcer of right buttock, stage 3 L89.314 Pressure ulcer of right buttock, stage 4 L89.323 Pressure ulcer of left buttock, stage 3 L89.324 Pressure ulcer of left buttock, stage 4 L89.43 Pressure ulcer of contiguous site of back, buttock and hip, stage 3 L89.44 Pressure ulcer of contiguous site of back, buttock and hip, stage 4 L89.503 Pressure ulcer of unspecified ankle, stage 3 L89.504 Pressure ulcer of unspecified ankle, stage 4 L89.513 Pressure ulcer of right ankle, stage 3 L89.514 Pressure ulcer of right ankle, stage 4 L89.523 Pressure ulcer of left ankle, stage 3 L89.524 Pressure ulcer of left ankle, stage 4 L89.603 Pressure ulcer of unspecified heel, stage 3 L89.604 Pressure ulcer of unspecified heel, stage 4 L89.613 Pressure ulcer of right heel, stage 3 L89.614 Pressure ulcer of right heel, stage 4 L89.623 Pressure ulcer of left heel, stage 3 L89.624 Pressure ulcer of left heel, stage 4 L89.813 Pressure ulcer of head, stage 3 L89.814 Pressure ulcer of head, stage 4 L89.893 Pressure ulcer of other site, stage 3 L89.894 Pressure ulcer of other site, stage 4 L89.93 Pressure ulcer of unspecified site, stage 3 L89.94 Pressure ulcer of unspecified site, stage 4

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T81.30XA Disruption of wound, unspecified, initial encounter T81.30XD Disruption of wound, unspecified, subsequent encounter T81.30XS Disruption of wound, unspecified, sequela T81.31XA Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter T81.31XD Disruption of external operation (surgical) wound, not elsewhere classified, subsequent encounter T81.31XS Disruption of external operation (surgical) wound, not elsewhere classified, sequela T81.32XA Disruption of internal operation (surgical) wound, not elsewhere classified, initial encounter T81.32XD Disruption of internal operation (surgical) wound, not elsewhere classified, subsequent encounter T81.32XS Disruption of internal operation (surgical) wound, not elsewhere classified, sequela T81.89XA Other complications of procedures, not elsewhere classified, initial encounter T81.89XD Other complications of procedures, not elsewhere classified, subsequent encounter T81.89XS Other complications of procedures, not elsewhere classified, sequela E08.621 Diabetes mellitus due to underlying condition with foot ulcer E09.621 Drug or chemical induced diabetes mellitus with foot ulcer E10.621 Type 1 diabetes mellitus with foot ulcer E11.621 Type 2 diabetes mellitus with foot ulcer E13.621 Other specified diabetes mellitus with foot ulcer I70.231 Atherosclerosis of native arteries of right leg with ulceration of thigh I70.232 Atherosclerosis of native arteries of right leg with ulceration of calf I70.233 Atherosclerosis of native arteries of right leg with ulceration of ankle I70.234 Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot I70.235 Atherosclerosis of native arteries of right leg with ulceration of other part of foot I70.238 Atherosclerosis of native arteries of right leg with ulceration of other part of lower leg I70.239 Atherosclerosis of native arteries of right leg with ulceration of unspecified site I70.241 Atherosclerosis of native arteries of left leg with ulceration of thigh I70.242 Atherosclerosis of native arteries of left leg with ulceration of calf I70.243 Atherosclerosis of native arteries of left leg with ulceration of ankle I70.244 Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot I70.245 Atherosclerosis of native arteries of left leg with ulceration of other part of foot I70.248 Atherosclerosis of native arteries of left leg with ulceration of other part of lower leg I70.249 Atherosclerosis of native arteries of left leg with ulceration of unspecified site I70.25 Atherosclerosis of native arteries of other extremities with ulceration I83.001 Varicose veins of unspecified lower extremity with ulcer of thigh I83.002 Varicose veins of unspecified lower extremity with ulcer of calf I83.003 Varicose veins of unspecified lower extremity with ulcer of ankle I83.004 Varicose veins of unspecified lower extremity with ulcer of heel and midfoot I83.005 Varicose veins of unspecified lower extremity with ulcer other part of foot I83.008 Varicose veins of unspecified lower extremity with ulcer other part of lower leg I83.009 Varicose veins of unspecified lower extremity with ulcer of unspecified site I83.011 Varicose veins of right lower extremity with ulcer of thigh I83.012 Varicose veins of right lower extremity with ulcer of calf I83.013 Varicose veins of right lower extremity with ulcer of ankle I83.014 Varicose veins of right lower extremity with ulcer of heel and midfoot I83.015 Varicose veins of right lower extremity with ulcer other part of foot I83.018 Varicose veins of right lower extremity with ulcer other part of lower leg I83.019 Varicose veins of right lower extremity with ulcer of unspecified site I83.021 Varicose veins of left lower extremity with ulcer of thigh I83.022 Varicose veins of left lower extremity with ulcer of calf I83.023 Varicose veins of left lower extremity with ulcer of ankle

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I83.024 Varicose veins of left lower extremity with ulcer of heel and midfoot I83.025 Varicose veins of left lower extremity with ulcer other part of foot I83.028 Varicose veins of left lower extremity with ulcer other part of lower leg I83.029 Varicose veins of left lower extremity with ulcer of unspecified site I83.201 Varicose veins of unspecified lower extremity with both ulcer of thigh and inflammation I83.202 Varicose veins of unspecified lower extremity with both ulcer of calf and inflammation I83.203 Varicose veins of unspecified lower extremity with both ulcer of ankle and inflammation I83.204 Varicose veins of unspecified lower extremity with both ulcer of heel and midfoot and inflammation I83.205 Varicose veins of unspecified lower extremity with both ulcer other part of foot and inflammation I83.208 Varicose veins of unspecified lower extremity with both ulcer of other part of lower extremity and inflammation I83.209 Varicose veins of unspecified lower extremity with both ulcer of unspecified site and inflammation I83.211 Varicose veins of right lower extremity with both ulcer of thigh and inflammation I83.212 Varicose veins of right lower extremity with both ulcer of calf and inflammation I83.213 Varicose veins of right lower extremity with both ulcer of ankle and inflammation I83.214 Varicose veins of right lower extremity with both ulcer of heel and midfoot and inflammation I83.215 Varicose veins of right lower extremity with both ulcer other part of foot and inflammation I83.218 Varicose veins of right lower extremity with both ulcer of other part of lower extremity and inflammation I83.219 Varicose veins of right lower extremity with both ulcer of unspecified site and inflammation I83.221 Varicose veins of left lower extremity with both ulcer of thigh and inflammation I83.222 Varicose veins of left lower extremity with both ulcer of calf and inflammation I83.223 Varicose veins of left lower extremity with both ulcer of ankle and inflammation I83.224 Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation I83.225 Varicose veins of left lower extremity with both ulcer other part of foot and inflammation I83.228 Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation I83.229 Varicose veins of left lower extremity with both ulcer of unspecified site and inflammation I87.311 Chronic venous hypertension (idiopathic) with ulcer of right lower extremity I87.312 Chronic venous hypertension (idiopathic) with ulcer of left lower extremity I87.313 Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity I87.319 Chronic venous hypertension (idiopathic) with ulcer of unspecified lower extremity I87.331 Chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity I87.332 Chronic venous hypertension (idiopathic) with ulcer and inflammation of left lower extremity I87.333 Chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity I87.339 Chronic venous hypertension (idiopathic) with ulcer and inflammation of unspecified lower extremity L89.003 Pressure ulcer of unspecified elbow, stage 3 L89.004 Pressure ulcer of unspecified elbow, stage 4 L89.013 Pressure ulcer of right elbow, stage 3 L89.014 Pressure ulcer of right elbow, stage 4 L89.023 Pressure ulcer of left elbow, stage 3 L89.024 Pressure ulcer of left elbow, stage 4 L89.103 Pressure ulcer of unspecified part of back, stage 3 L89.104 Pressure ulcer of unspecified part of back, stage 4 L89.113 Pressure ulcer of right upper back, stage 3

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L89.114 Pressure ulcer of right upper back, stage 4 L89.123 Pressure ulcer of left upper back, stage 3 L89.124 Pressure ulcer of left upper back, stage 4 L89.133 Pressure ulcer of right lower back, stage 3 L89.134 Pressure ulcer of right lower back, stage 4 L89.143 Pressure ulcer of left lower back, stage 3 L89.144 Pressure ulcer of left lower back, stage 4 L89.153 Pressure ulcer of sacral region, stage 3 L89.154 Pressure ulcer of sacral region, stage 4 L89.203 Pressure ulcer of unspecified hip, stage 3 L89.204 Pressure ulcer of unspecified hip, stage 4 L89.213 Pressure ulcer of right hip, stage 3 L89.214 Pressure ulcer of right hip, stage 4 L89.223 Pressure ulcer of left hip, stage 3 L89.224 Pressure ulcer of left hip, stage 4 L89.303 Pressure ulcer of unspecified buttock, stage 3 L89.304 Pressure ulcer of unspecified buttock, stage 4 L89.313 Pressure ulcer of right buttock, stage 3 L89.314 Pressure ulcer of right buttock, stage 4 L89.323 Pressure ulcer of left buttock, stage 3 L89.324 Pressure ulcer of left buttock, stage 4 L89.43 Pressure ulcer of contiguous site of back, buttock and hip, stage 3 L89.44 Pressure ulcer of contiguous site of back, buttock and hip, stage 4 L89.503 Pressure ulcer of unspecified ankle, stage 3 L89.504 Pressure ulcer of unspecified ankle, stage 4 L89.513 Pressure ulcer of right ankle, stage 3 L89.514 Pressure ulcer of right ankle, stage 4 L89.523 Pressure ulcer of left ankle, stage 3 L89.524 Pressure ulcer of left ankle, stage 4 L89.603 Pressure ulcer of unspecified heel, stage 3 L89.604 Pressure ulcer of unspecified heel, stage 4 L89.613 Pressure ulcer of right heel, stage 3 L89.614 Pressure ulcer of right heel, stage 4 L89.623 Pressure ulcer of left heel, stage 3 L89.624 Pressure ulcer of left heel, stage 4 L89.813 Pressure ulcer of head, stage 3 L89.814 Pressure ulcer of head, stage 4 L89.893 Pressure ulcer of other site, stage 3 L89.894 Pressure ulcer of other site, stage 4 L89.93 Pressure ulcer of unspecified site, stage 3 L89.94 Pressure ulcer of unspecified site, stage 4 T81.30XA Disruption of wound, unspecified, initial encounter T81.30XD Disruption of wound, unspecified, subsequent encounter T81.30XS Disruption of wound, unspecified, sequela T81.31XA Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter T81.31XD Disruption of external operation (surgical) wound, not elsewhere classified, subsequent encounter T81.31XS Disruption of external operation (surgical) wound, not elsewhere classified, sequela T81.32XA Disruption of internal operation (surgical) wound, not elsewhere classified, initial encounter T81.32XD Disruption of internal operation (surgical) wound, not elsewhere classified, subsequent encounter

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T81.32XS Disruption of internal operation (surgical) wound, not elsewhere classified, sequela T81.89XA Other complications of procedures, not elsewhere classified, initial encounter T81.89XD Other complications of procedures, not elsewhere classified, subsequent encounter T81.89XS Other complications of procedures, not elsewhere classified, sequela

The following CPT and HCPCS codes are considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity:

CPT Codes CPT codes:

Code Description 97607 Negative pressure wound therapy, (eg, vacuum assisted drainage collection), 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 less than or equal to 50 square centimeters 97608 Negative pressure wound therapy, (eg, vacuum assisted drainage collection), 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 greater than 50 square centimeters HCPCS Codes HCPCS codes: Code Description A9272 Mechanical wound suction, disposable, includes dressing and all accessories and components, each

Description Chronic Wound Management The management and treatment of chronic wounds, including decubitus ulcers, is challenging. Most chronic wounds will heal only if the underlying cause (ie, venous stasis, pressure, infection) is addressed. Also, cleaning the wound to remove nonviable tissue, microorganisms, and foreign bodies is essential to create optimal conditions for either re-epithelialization (ie, healing by secondary intention) or preparation for wound closure with skin grafts or flaps (ie, healing by primary intention). Therefore, debridement, irrigation, whirlpool treatments, and wet-to-dry dressings are common components of chronic wound care.

Negative pressure wound therapy (NPWT) involves the use of a negative pressure or suction device to aspirate and remove fluids, debris, and infectious materials from the wound bed to promote the formation of granulation tissue. The devices may also be used as an adjunct to surgical therapy or as an alternative to surgery in a debilitated patient. Although the exact mechanism has not been elucidated, it is hypothesized that negative pressure contributes to wound healing by removing excess interstitial fluid, increasing the vascularity of the wound, reducing edema, and/or creating beneficial mechanical forces that lead to cell growth and expansion.

Summary of Evidence The focus of this evidence review is the use of NPWT in the outpatient setting. It is recognized that patients may begin using the device in the inpatient setting and then transition to the outpatient setting.

For individuals who have diabetic lower-extremity ulcers or amputation wounds who receive outpatient negative pressure wound therapy (NPWT), the evidence includes systematic reviews of randomized controlled trials (RCTs). Relevant outcomes are symptoms, change in disease status, morbid events, quality of life (QOL), and treatment-related morbidity. There was a higher rate of wound healing and fewer amputations with NPWT, although the studies were at risk of bias due to lack of

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blinding. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have diabetic lower-extremity ulcers or amputation wounds who receive portable, single-use outpatient NPWT, the evidence includes RCTs. Relevant outcomes are symptoms, change in disease status, morbid events, QOL, and treatment-related morbidity.
• A 2019 RCT compared the PICO device with standard NPWT. In this study, the PICO device demonstrated noninferiority for wound area reduction. A statistically significant benefit in complete wound closure was noted for patients with diabetic foot ulcers but was not duplicated in the per protocol population due to a high number of exclusions.
• One study of the SNaP System showed noninferiority to a V.A.C. device for wound size reduction. No significant difference in complete wound closure was reported. Interpretation of this study is limited by a high loss to follow-up.
Well-designed comparative studies with larger numbers of patients powered to detect differences in complete wound closure are needed. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. For individuals who have chronic pressure ulcers who receive outpatient NPWT, the evidence includes RCTs and systematic reviews. Relevant outcomes are symptoms, change in disease status, morbid events, QOL, and treatment-related morbidity. All trials are of low quality and at high risk of bias. Also, most study populations were treated in inpatient settings. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have lower-extremity ulcers due to venous insufficiency who receive outpatient NPWT, the evidence includes an RCT and a systematic review. Relevant outcomes are symptoms, change in disease status, morbid events, QOL, and treatment-related morbidity. A single RCT in patients with nonhealing leg ulcers who were treated with skin grafts found a faster rate of healing with NPWT when used in the inpatient setting. No studies were identified on the effectiveness of NPWT as a primary treatment for leg ulcers or for the use of NPWT in the outpatient setting. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have lower-extremity ulcers due to venous insufficiency who receive portable, single- use outpatient NPWT, the evidence includes RCTs. Relevant outcomes are symptoms, change in disease status, morbid events, QOL, and treatment-related morbidity. A 2019 RCT compared the PICO device with standard NPWT. In this study, the PICO device demonstrated noninferiority for wound area reduction. No significant benefit in complete wound closure was found in patients with venous ulcers. One study of the SNaP System showed noninferiority to a V.A.C. device for wound size reduction. A subgroup analysis of this study found a significant difference in complete wound closure for patients with venous ulcers. However, interpretation of this study is limited by a high loss to follow-up and lack of a control group treated with standard dressings. Well-designed comparative studies with larger numbers of patients powered to detect differences in complete wound closure are needed. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. For individuals who have burn wounds who receive outpatient NPWT, the evidence includes RCTs, systematic reviews, and case series. Relevant outcomes are symptoms, change in disease status, morbid events, QOL, and treatment-related morbidity.
• An interim report of an RCT evaluating NPWT in partial-thickness burns, summarized in a Cochrane review, did not permit conclusions on the efficacy of NPWT for this indication.
• A separate RCT comparing NPWT with split-skin grafts in patients with full-thickness burns did not show differences in graft take and wound epithelialization.
• A retrospective case series reported good functional outcomes for most patients who were treated with NPWT at a single center.
• A meta-analysis of international trials found that NPWT was associated with faster healing times; however, the analysis was limited by substantial heterogeneity, inconsistent intervention protocols, and a moderate risk of bias across several studies. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

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For individuals who have traumatic or surgical wounds who receive NPWT, the evidence includes RCTs and systematic reviews. Relevant outcomes are symptoms, change in disease status, morbid events, QOL, and treatment-related morbidity. Systematic reviews of RCTs in patients with surgical wounds have generally found lower risk of SSI; however, many studies are limited to short-term use of NPWT limiting applicability to the outpatient setting. For patients with traumatic wounds, a Cochrane review failed to find significant improvement in patients treated with NPWT. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have traumatic or surgical wounds who receive portable, single-use outpatient NPWT, the evidence includes RCTs. Relevant outcomes are symptoms, change in disease status, morbid events, QOL, and treatment-related morbidity. The PICO device was studied in an adequately powered but unblinded RCT of combined in- and outpatient use after total joint arthroplasty and a single-center RCT of combined in- and outpatient use after cesarean delivery in women with obesity. The evidence base for the Prevena System is not sufficiently robust for conclusions on efficacy to be drawn. Well- designed comparative studies with larger numbers of patients treated in an outpatient setting are needed. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Policy History Date Action
3/2026 Annual policy review. Policy updated with literature review through November 14, 2025; references added. Policy statements unchanged.
11/2024
Annual policy review. Policy clarified and reformatted. Policy statements unchanged. Prior authorization is no longer required. Procedure-to-diagnoses edits implemented. 9/2023 Policy clarified to include prior authorization requests using Authorization Manager. 3/2023 Annual policy review. Not medically necessary language changed to Investigational; other minor editorial refinements to policy statements; intent unchanged. 6/2022 Prior authorization information clarified for PPO plans. Effective 6/1/2022. 6/2021 Clarified authorization statement 4/2021 Annual policy review. Description, summary and references updated. Policy statements unchanged. 1/2021 Medicare information removed. See MP #132 Medicare Advantage Management for local coverage determination and national coverage determination reference.
3/2020 Annual policy review. Description, summary and references updated. Policy statements unchanged. 3/2019 Annual policy review. Description, summary and references updated. Policy statements unchanged. 2/2018 Annual policy review. New references added. 2/2017 Annual policy review. New references added. 3/2016 Annual policy review. New references added. 3/2015 Annual policy review. New references added. Clarified coding information. 1/2015 Clarified coding information. 7/2014 Updated Coding section with ICD10 procedure and diagnosis codes, effective 10/2015. 4/2014 Annual policy review. New references added. 3/2014 Coding information clarified. 2/1/2013 Annual policy review. No change in medical policy statement.
2/1/2013 New policy describing ongoing coverage and non-coverage statements.
Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

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References

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Endnotes

1 Based on expert opinion