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:
• Removal of excess fluid;
• Increased blood flow and decreased
bacterial colonization;
• Granulation tissue formation;
and
• Partial or complete wound closure
with or without the need for additional procedures.
4.0 POLICY
4.1 An 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 calendar
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.