3.0 DESCRIPTION
NPWT applies a localized vacuum to draw the
edges of an open wound together while providing a moist environment
conducive to rapid wound healing. NPWT is also known as Topical Negative
Pressure (TNP) and Vacuum-Assisted Closure (VAC). The goal of NPWT
is to create a controlled, closed wound amenable to surgical closure,
grafting, or healing by secondary intention. An evacuation tube
is embedded in a dressing made of foam. After thorough wound debridement,
the foam dressing is placed within the wound bed and covered by
a dressing to form an airtight seal, and the tube is attached to
a vacuum unit. Continuous or intermittent negative pressure is applied.
The amount of pressure is determined by the wound type. NPWT is
designed to result in: (1) removal of excess fluid; (2) increased
blood flow and decreased bacterial colonization; (3) granulation
tissue formation; and (4) partial or complete wound closure with
or without the need for additional procedures.
4.0 POLICY
4.1 A NPWT
pump and supplies are covered when one of the following conditions
exists:
4.1.1 Complications of surgically created wound (e.g.,
dehiscence, poststernotomy disunion with exposed sternal bone, poststernotomy
mediastinitis, or postoperative disunion of the abdominal wall).
4.1.2 Traumatic
wound (e.g., preoperative flap or graft, exposed bones, tendons,
or vessels) and a need for accelerated formation of granulation
tissue not achievable by other topical wound treatments (e.g., the
individual has comorbidities that will not allow for healing times
usually achievable with other available topical wound treatments).
4.1.3 Chronic
nonhealing Stage III or IV pressure ulcer, diabetic neuropathic
ulcer or chronic venous ulcer with lack of improvement for at least
the previous 30 days despite standard wound therapy, including the
application of moist topical dressings, debridement of necrotic
tissue (if present), maintenance of an adequate nutritional status,
and weekly evaluations with documentation of wound measurements
(i.e., length, width, and depth).
4.2 NPWT is
covered:
4.2.1 Only after careful consideration has been given
to the following risk factors:
• Patients with friable
vessels and infected blood vessels, sharp edges in the wound (i.e., bone
fragments), or Spinal Cord Injury (SCI) (stimulation of sympathetic
nervous system);
• Patients
requiring Magnetic Resonance Imaging (MRI), hyperbaric chamber, defibrillation;
• Patient size and weight;
• Use near vagus nerve
(bradycardia);
• Circumferential
dressing application;
• Mode of therapy-intermittent
versus continuous negative pressure.
4.2.2 For a period
of up to four months (including the time NPWT was applied in an
inpatient setting prior to discharge to the home) in the treatment
of any wound. The medical necessity of NPWT beyond four months will
be given individual consideration based upon required additional documentation
including but not limited to:
4.2.2.1 Documentation
of progression of healing of the wound on two successive dressing changes,
as determined by quantitative measurements of wound characteristics
including wound length and width (surface area), or depth, serially
observed and documented; and
4.2.2.2 Documentation
of appropriate medical professional supervision or performance of
weekly wound measurement and assessment functions as well as the
negative pressure wound therapy dressing changes required; or
4.2.3 In the
judgment of the treatment physician, until adequate wound healing
has occurred to the degree that NPWT may be discontinued; or
4.2.4 Until equipment
or supplies are no longer being used for the patient, whether or
not by the physician’s order.
4.3 When the patient is monitored
frequently in an appropriate care setting by a licensed health care
professional. Frequency of monitoring shall be determined by the
patient’s condition, wound status, wound location, and co-morbidities.
4.4 When the
patient is determined to be a proper candidate for using the NPWT
system at home, a licensed health care professional will ensure
the patient receives appropriate training prior to using the NPWT
system to include:
• Demonstration and
documentation of the patient’s proficiency in using the system;
• Potential complications
and their signs and symptoms, and what to do if complications occur;
• Ensuring patient understanding
of the warnings associated with NPWT system use; and
• Providing patient
with a written copy of the patient labeling from the NPWT manufacturer, if
available.
4.5 A licensed health care professional,
for the purposes of this policy, may be a physician, Physician’s
Assistant (PA), Registered Nurse (RN), Licensed Practical Nurse
(LPN), or Physical Therapist (PT). The practitioner should be licensed
to assess wounds and/or administer wound care within the state where
the beneficiary is receiving NPWT.
5.0 EXCLUSIONs
5.1 An NPWT
pump and supplies are excluded under any of the following conditions:
5.1.1 For patients
whose wounds respond to standard therapeutic measures.
5.1.2 The patient
cannot tolerate the use of NPWT.
5.1.3 For patients with the following
contraindications:
• Active bleeding;
• Anticoagulant use;
• Difficult wound
hemostasis;
• Exposed
organs;
• Exposed
vasculature;
• Exposed
nerves;
• Exposed
anastomotic site;
• Inadequately debrided
wounds;
• Untreated
osteomyelitis;
• Necrotic tissue
with eschar present;
• Infection in the
wound;
• Malignancy
in the wound; and
• Non-enteric and
unexplored fistulas.
5.1.4 Uniform
granulation tissue has been obtained.
5.1.5 The depth of the wound is
less than one mm, as wounds of this depth cannot accommodate the
sponge.