Osteomyelitis within the vicinity of the wound that is not concurrently being treated with intent to cure or.The presence in the wound of necrotic tissue with eschar, if debridement is not attempted or.Note: NPWT is usually administered once-weekly.Īn NPWT pump and supplies is considered not medically necessary if one or more of the following contraindications are present: See specifications of equipment and supplies in the Appendix. Therefore, more than 1 NPWT pump billed per member for the same time period is considered not medically necessary. Note: NPWT pumps must be capable of accommodating more than 1 wound dressing set for multiple wounds on a member. In either situation for Section B.1 or B.2, NPWT will be considered medically necessary when treatment continuation is ordered beyond discharge to the home setting. Management of fasciotomy wounds in persons with compartment syndrome.The member has complications of a surgically created wound (e.g., dehiscence) or a traumatic wound (e.g., pre-operative flap or graft ) where there is documentation of the medical necessity for accelerated formation of granulation tissue which can not be achieved by other available topical wound treatments (e.g., other conditions of the member that will not allow for healing times achievable with other topical wound treatments).An ulcer or wound (described in Section A above) is encountered in the inpatient setting and, after wound treatments described in Sections A.1 through A.4 for the various types of ulcers above have been tried or considered and ruled out, it is necessary to initiate NPWT.Ulcers and Wounds Encountered in an Inpatient Setting.Leg elevation and ambulation have been encouraged.Compression bandages and/or garments have been consistently applied, and.Reduction in pressure on a foot ulcer has been accomplished with appropriate modalities.The member has been on a comprehensive diabetic management program, and.For neuropathic (e.g., diabetic) ulcers :.The member's moisture and incontinence have been appropriately managed. The member has used a group 2 or 3 support surface for pressure ulcers on the posterior trunk or pelvis (see CPB 0430 - Pressure Reducing Support Surfaces) Note: A group 2 or 3 support surface is not required if the ulcer is not on the trunk or pelvis and.The member has been appropriately turned and positioned, and.Evaluation of and provision for adequate nutritional status.Documentation of evaluation, care, and wound measurements by a licensed medical professional, and.Debridement of necrotic tissue if present, and.Application of dressings to maintain a moist wound environment, and.General measures of wound therapy programįor all ulcers or wounds, the following components of a wound therapy program must include a minimum of all of the following general measures, which should either be addressed, applied, or considered and ruled out prior to application of NPWT:.A complete wound therapy program described by criterion 1 and criteria 2, 3, or 4 below, as applicable depending on the type of wound, has been tried or considered and ruled out prior to application of NPWT. The member has a chronic Stage III or IV pressure ulcer (see Appendix below), neuropathic ulcer (e.g., diabetic ulcer), venous or arterial insufficiency ulcer, or a chronic ulcer of mixed etiology, present for at least 30 days. This Clinical Policy Bulletin addresses negative pressure wound therapy.Īetna considers negative pressure wound therapy (NPWT) pumps medically necessary, when either of the following criteria (A or B) is met: Number: 0334 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References
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