UM Guidelines

	Added:
	Exceptions may be required to comply with EPSDT & TennCare regulations.
	Description of Wound Care Wound care is a medically prescribed treatment of a break in the skin. Wound care is usually ordered for complex, nonhealing wounds. A chronic non-healing wound is one that has not demonstrated notable improvement after four weeks, or one that has not healed after a period of eight weeks. There are multiple types of wounds such as venous stasis ulcers, surgical wounds, burns, and pressure ulcers. Pressure ulcer is any lesion caused by unrelieved pressure resulting in damage of underlying tissue, which are classified as follows: Stage I is nonblanchable erythema of intact skin - the first lesion of skin ulceration. With darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be indicators. Stage II is partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Stage III is full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Stage IV is full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts may also be associated with Stage IV pressure ulcers. Venous stasis ulcers are caused by chronic venous insufficiency, a condition that occurs when blood pools in the veins of the lower legs. This can cause leg swelling, changes in the skin texture and color, and skin ulcers in the top layer of the skin of the lower legs. Wound color may indicate the following: Black: necrotic tissue that is non-viable, and must be removed before healing can take place Yellow: possibly moist necrotic tissue or slough and/or purulent drainage Red: granulation tissue, which begins to form in the actively healing phase of a wound Debridement is the removal of foreign material and/or devitalized or contaminated tissue from or adjacent to a traumatic or infected lesion until surrounding healthy tissue is exposed. Debridement, which may be referred to as sharp debridement, involves the use of surgical instruments such as a scalpel, laser, curette or electrocautery. There are four types of debridement methods: Autolytic – a moisture retentive dressing Enzymatic – application of debridement agents Mechanical – wet or moist dressings Sharp – surgical removal of tissue Wound Care Criteria If a covered benefit, wound care may be approved for members when all of the following are present: Performed by or under the direct supervision of a physician Prescribed by a physician with a signed and dated written order for the wound care to include: Type of dressing Number of dressings used at one time (if more than one) Frequency of dressing changes Expected duration of services Services must require the skills of and be performed by a medical professional licensed in the state they are practicing Services must be considered acceptable standards of medical practice that are specific to the treatment of the individual’s condition Services for debridement are performed only by doctors of medicine, osteopathy and podiatry. Allied health professionals can perform these services only if they are adequately trained and if these services are within the scope of practice of their state license act. Services rendered must include instruction to the individual & family/caregiver that includes teaching of home program The individual must make reasonable progress within a reasonable and generally predictable period of time The equipment and devices used in the treatment of wounds must be FDA approved Documentation should include the following: Notes & evaluations, signed and dated by the licensed health care provider Type of treatment modality Compliance, cooperation, & ability of the individual &/or caregiver to comprehend the written treatment regimen & goals Individualized treatment plan Interventions to stabilize and manage all underlying medical conditions, including but not limited to: Diabetes Edema Venous insufficiency Arterial insufficiency Incontinence Dietary, nutritional and hydration deficiency Infection Initial evaluation and reevaluation of the wound Reevaluation is performed because of: New clinical indications; or Failure to respond to interventions; or Failure to establish progress from baseline data Wound care is appropriate for, but not limited to, any of the following conditions: Pressure ulcers stage I through IV Full or partial thickness wounds that fail to show significant clinical improvement in four weeks Full thickness wounds with exposed tendon, bone and/or joint Wounds in compromised individuals, especially those with diabetes mellitus Clostridial myonecrosis - gas gangrene Other necrotizing soft tissue (subcutaneous, muscle, fascia) infections Refractory osteomyelitis Radiation tissue injury (soft tissue and osteoradionecrosis) Crush injury, compartment syndromes and other acute traumatic ischemic injuries Compromised or failed skin grafts and flaps Thermal burns Neuropathic ulcers (e.g., diabetic) Venous or arterial insufficiency ulcers unresponsive to standard therapy Surgically created wound (e.g., dehiscence) Assessment Requirements (Evaluation & Plan of Care) Evaluation and reevaluation should demonstrate actual hand-on assessment occurred as opposed to a limited screening assessment and include the following documentation: History and any previous treatment of the wound (for initial evaluation) Ordering MD The date of exam Location and shape of the wound Measurement of the wound to include length, width and depth Presence or absence of a sinus or undermining with description Description of the wound and surrounding tissue, to include color, odor, warmth, tenderness, etc. Quantity and description of the drainage Results of wound cultures Presence of granulation and/or necrotic tissue Any debridement of necrotic tissue if present including the type and level of tissue or material removed Treatment provided Response to treatment Understanding of the individual and/or caregivers regarding the condition and willingness/ability to comply with the care Compliance with the treatment Change in orders and treatment plan Assessment of any contributing factors (e.g., diabetes, edema, dietary status, environmental factors) Plan of care should include the following: Long & short-term measurable goals and expected outcomes Discharge goals Measurable objectives Functional objectives Home program if applicable Duration of treatment Frequency of treatment Date therapy to begin Description of the treatment Wound healing treatment should include: Implementation of physician’s orders Instruction to the individual and caregiver on the management of the wound Regular assessment by a nurse, physician or other licensed health care practitioner (usually weekly for Stage III or IV ulcer) Notification to physician of wound status as scheduled or as needed due to change Appropriate mobility and/or turning and positioning Appropriate wound care Appropriate management of moisture and incontinence Nutritional assessment (i.e., protein level) and intervention consistent with the overall plan of care Treatment of all underlying medical conditions Management of pain Types of treatment modalities Soaks Wet to dry dressings Whirlpool therapy Debridement methods: Autolytic – a moisture retentive dressing Enzymatic – application of debridement agents Mechanical – wet or moist dressings Sharp – surgical removal of tissue Topical creams Topical antimicrobials Oral antibiotics Plain and/or special dressings Hydrogen peroxide Pressure bandages Intermittent pneumatic compression therapy Total contact casting Hyperbaric oxygen Negative pressure wound therapy pump Indications of wound healing include the following: Reduction of surrounding tissue erythema, edema, or induration; Lack of eschar and necrotic tissue Granulation of tissue which is pale pink to beefy red in color Reduction of wound depth Contraction of the wound Drainage/exudate less purulent and malodorous and more serous in nature Completion of epithelialization Authorization of Services (If required or requested) A limited number of visits should be authorized initially The number of visits authorized is based on medical considerations For an extension to be considered, reevaluation and information is required as indicated under Section III Assessment Requirements Limitations (Services not covered) Services that are determined to be not medically necessary Services that do not require the skills of a licensed medical professional Services for which the documentation indicates no reasonable progress Sources American Medical Directors Association. (1996). Pressure ulcers. Retrieved March 1, 2006 from http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=1811&string=pressure+AND+ulcers. American Medical Directors Association. (1999). Pressure ulcer therapy companion. Retrieved March 1, 2006 from http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=2159&string=pressure+AND+ulcers. Bergstrom, N., Allman, R. M., Alvarez, O. M., Bennett, A. M., Carlson, C. E., Frantz, R. A., et al. (1994). Treatment of pressure ulcers. Clinical Practice Guideline, No. 15. Retrieved February 28, 2007 from http://www.medicaledu.com/ahcpr.htm. BlueCross BlueShield Association. Medical Policy Reference Manual. (5:2006). Negative Pressure Therapy for the Treatment of Chronic Wounds (1.01.16). Retrieved February 27, 2007 from BlueWeb. BlueCross BlueShield Association. Medical Policy Reference Manual. (1:2006). Noncontact radiant heat bandage for the treatment of wounds (2.01.41). Retrieved February 27, 2007 from BlueWeb. McGuckin, M., Stineman, M., Goin, J., & Williams, S. (1996). Draft guideline: Diagnosis and treatment of venous leg ulcers. Ostomy/Wound Management, 42 (4), 48-57.