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.