Humana Commercial Clinical Policy

Humana Negative Pressure Wound Therapy Form


Effective Date

03/23/2023

Last Reviewed

NA

Original Document

  Reference



Description

Negative pressure wound therapy (NPWT), also called vacuum assisted wound closure, refers to wound dressing systems that continuously or intermittently apply subatmospheric pressure to the surface of a wound. NPWT is most commonly used in the treatment of acute and chronic wounds such as surgical wounds, various soft tissue injuries or ulcers (eg, diabetic foot, pressure and venous leg). This technique may also be prescribed to promote healing prior to using a flap or skin graft by advancing early healing of the site, thereby preparing the wound bed for surgical reconstruction. NPWT involves the application of a localized vacuum to the wound surface to draw the edges of the wound together.

NPWT devices are available as rental (portable) or disposable (single-use) units.

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Negative Pressure Wound Therapy

Effective Date: 03/23/2023
Revision Date: 03/23/2023
Review Date: 03/23/2023
Policy Number: HUM-0454-022

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

The NPWT device consists of a dressing of gauze and/or open-celled reticulated foam that is placed in the wound. A tube is embedded into the dressing and sealed with an adhesive transparent dressing. Attached to the tube is a vacuum pump which applies negative pressure to the wound. This pressure drains fluid and exudates from the wound to a disposable canister. The intent of this treatment is to help reduce edema, improve vascularity and oxygenation of the wound bed, provide a moist environment and help stimulate healthy granulation tissue conducive to rapid wound healing.

Negative pressure wound therapy placement over surgically closed incisions is an alternative to absorbent dressings, gauze and adhesive medical tape (eg, npSIMS, Prevena, Prevena Duo and Prevena Restor Incision Management System). Purportedly intended to promote healing by holding incision sides closed, removing fluid and reducing the incidence of seromas and surgical site infections. (Refer to Coverage Limitations section)

Negative pressure wound therapy with instillation (NPWTi) is the combination of NPWT with timed, intermittent delivery of a topical solution. The fluid reportedly helps to remove wound exudate, slough and bacteria to purportedly promote more rapid healing of the wound. The solution is delivered and remains in the wound for a set amount of time and subsequently removed via NPWT. (Refer to Coverage Limitations section)

Examples of NPWT devices include, but may not be limited to:
  • Rental (Portable) Units
    • ActiV.A.C. Therapy Unit
    • CATALYST
    • Invia Liberty NPWT System
    • RENASYS GO
    • SVED Wound Treatment System
    • V.A.C. Freedom Therapy Unit
  • NPWTi Units (Refer to Coverage Limitations section)
    • V.A.C.Ulta NPWTi System
    • V.A.C. Veraflo Therapy

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Single-Use, Disposable Units (Refer to Coverage Limitations section)
  • Avelle Negative Pressure Wound Therapy System
  • Invia Motion NPWT Systems (available in six versions with different run times)
  • MyNeWT Negative Pressure Wound System
  • Nexa Negative Pressure Wound Therapy System
  • npSIMS Negative Pressure Surgical Incision Management System (npSIMS)
  • PICO and PICO 7Y Single Use Negative Pressure Wound Therapy Wound System
  • Prevena, Prevena Duo and Prevena Restor Incision Management System
  • PWD Negative Pressure Wound Therapy System
  • SNaP Wound Care System
  • UNO Negative Pressure Wound Therapy System
  • V.A.C. Via Therapy System

Coverage Determination

Humana members may be eligible under the Plan for the initiation of a rental (portable) NPWT device and 30 days of treatment when the following criteria are met:

  • Absence of contraindications; AND
  • Chronic, nonhealing ulcer with lack of improvement greater than 30 days duration despite standard wound therapy and weekly evaluations by an appropriate licensed medical professional with documentation of wound measurements (eg, length, width and depth) AND ONE of the following criteria are met:
    • Chronic neuropathic (diabetic) ulcer:
      • Documentation of hemoglobin A1c (HbA1c); AND
      • Individual has been referred to a comprehensive diabetic management program; AND
      • Reduction in pressure on a foot ulcer has been accomplished with appropriate modalities; OR
    • Chronic stage 3 or stage 4 pressure injury:
      • Moisture and incontinence have been addressed; AND
      • Reduction in pressure on the posterior trunk or pelvis injuries have been accomplished with appropriate modalities; AND
      • Turning and repositioning regimens have been performed; OR
    • Chronic venous ulcer:
      • Compression garments/dressings have been consistently applied; AND
      • Leg elevation and ambulation have been encouraged; AND
      • Vascular evaluation and correction of varicosities have been performed; OR
  • Adjunct treatment for complications of a surgically created wound (eg, dehiscence, wound with exposed hardware or bone, poststernotomy mediastinitis or postoperative disunion of the abdominal wall); OR
  • Adjunct treatment of a traumatic wound (eg, preoperative flap or graft, exposed bones and tendons) and a need for accelerated formation of granulation tissue not achievable by other topical wound treatments (eg, the individual has comorbidities that will not allow for healing times usually achievable with other available topical wound treatments)

Humana members may be eligible under the Plan for the continuation of NPWT treatment for an additional 30 days for the treatment of wounds when documentation is provided by an appropriate licensed medical professional and ALL of the following criteria are met:

  • Measurable improvement in the wound (eg, wound dimensions and characteristics), if no surgical debridement has occurred in the last 30 days OR since last wound measurement; AND
Negative Pressure Wound Therapy

Effective Date: 03/23/2023
Revision Date: 03/23/2023
Review Date: 03/23/2023
Policy Number: HUM-0454-022
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Provisions are made for adequate nutritional status (normal albumin, prealbumin, protein levels) if abnormal; AND
  • Underlying medical conditions (eg, diabetes mellitus, venous insufficiency) are being appropriately managed (eg, HbA1c test should be done quarterly in an individual whose therapy has changed or is not meeting glycemic goals3)

Coverage for NPWT, if all of the above criteria continue to be met, should last a maximum of 3 months (including both inpatient and outpatient treatment time).

Commercial Plan members: all requests for NPWT beyond 3 consecutive months, require review by a medical director.

Coverage for NPWT will be discontinued at the time ANY of the following occur:

  • Equipment or supplies are no longer being used (by individual discretion or the physician’s order); OR
  • Individual cannot tolerate the use of NPWT; OR
  • No measurable degree of wound healing has occurred over the prior month (unless documentation shows surgical debridement as the cause for larger measurements); OR
  • Uniform granulation tissue has been obtained; OR
  • Wound depth can no longer accommodate the sponge as reticulated foam dressing should not overlap onto intact skin

Coverage for NPWT supplies will be provided as follows:

  • Up to a maximum of 15 dressing kits (A6550) per month
  • Up to a maximum of 10 canister sets (A7000) per month
Negative Pressure Wound Therapy

Effective Date: 03/23/2023
Revision Date: 03/23/2023
Review Date: 03/23/2023
Policy Number: HUM-0454-022
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Coverage Limitations

Humana members may NOT be eligible under the Plan for NPWT devices in wounds that have responded to standard therapeutic measures OR for individuals with the following contraindications:

  • Exposed vital organs; OR
  • Fistulas to organs or body cavities; OR
  • Malignancy in the wound; OR
  • Necrotic tissue with eschar; OR
  • Placement over exposed arteries or veins; OR
  • Placement over exposed nerves; OR
  • Presence of exposed anastomotic sites (located at the site of the surgical connection of two tubular structures); OR
  • Untreated osteomyelitis

These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Negative Pressure Wound Therapy

Effective Date: 03/23/2023
Revision Date: 03/23/2023
Review Date: 03/23/2023
Policy Number: HUM-0454-022
Page: 7 of 21

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Inadequate wound hemostasis; OR
  • Inadequately debrided wounds; OR
  • Untreated cellulitis; OR
  • Use of anticoagulation (eg, apixaban [Eliquis], dabigatran [Pradaxa], edoxaban [Savaysa], enoxaparin [Lovenox], fondaparinux [Arixtra], heparin, rivaroxaban [Xarelto], warfarin [Coumadin]); but excluding antiplatelet agents (eg, aspirin, clopidogrel [Plavix], dipyridamole [Persantine], dipyridamole/aspirin [Aggrenox], eptifibatide [Integrilin], prasugrel [Effient], ticagrelor [Brilinta], ticlopidine [Ticlid])

These are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member's individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for NPWT devices for any indications other than those listed above including, but may not be limited to, the following:

  • NPWTi; OR
  • Placement over surgically closed incisions; OR
  • Single use, disposable NPWT devices

These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Additional information about wounds and wound management may be found from the following websites: Background

  • National Library of Medicine
Negative Pressure Wound Therapy

Effective Date: 03/23/2023
Revision Date: 03/23/2023
Review Date: 03/23/2023
Policy Number: HUM-0454-022
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Medical Alternatives

Alternatives to NPWT include, but may not be limited to, the following:

  • Dressing changes appropriate for the type and condition of the wound including, but may not be limited to:
    • Absorptive
    • Alginate
    • Collagen
    • Composite
    • Compression
    • Foam
    • Hydrocolloid
    • Hydrogel
  • Electrical stimulation (please refer to Electrical Stimulation and Electromagnetic Therapy for the Treatment of Wounds Medical Coverage Policy)
  • Hyperbaric oxygen treatment (HBOT) (please refer to Hyperbaric Oxygen Therapy, Topical Oxygen Therapy Medical Coverage Policy)
  • Surgical repairs (eg, direct closure, skin flap, skin grafting)

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Humana may offer a disease management program for this condition. The member may call the number on his/her identification card to ask about our programs to help manage his/her care.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

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