Negative Pressure Wound Therapy in the Outpatient Setting
Negative pressure wound therapy (NPWT) consists of the use of a negative pressure or suction device to aspirate and remove fluids, debris, and infectious materials from the wound bed to promote the formation of granulation tissue. These devices may also be used as an adjunct to surgical therapy or as an alternative to surgery in an individual who is debilitated. The use of NPWT should be part of a comprehensive wound care program that includes frequent monitoring by a trained practitioner.
NPWT uses a specialized dressing and vacuum drainage to remove blood or serous fluid from a wound or operation site while maintaining a moist wound environment. It is delivered through an integrated system of a suction pump, separate exudate collection chamber and dressing sets to a qualified wound. When the exposed end of the drain tube is connected to sub-atmospheric pressure or a vacuum source, fluid is drawn from the wound through the foam into a reservoir, for subsequent disposal.
Negative pressure wound therapy may be delivered using mechanically powered or electrically powered devices.Non-powered (mechanical) devices are designed to be light-weight, disposable, and may be worn underneath clothing.
Powered negative pressure wound therapy may be considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below).
Non-powered negative pressure wound therapy devices for the treatment of wounds are considered investigational.
Powered negative pressure wound therapy is considered medically appropriate if ALL of the following have been met:
Powered negative pressure wound therapy device is indicated for ANY ONE of the following:
Initial 30 day trial for ANY ONE of the following qualifying wounds:
Stage III or IV pressure ulcer when ALL of the following are met:
Wound has failed to heal after 90 days of optimal wound care (e.g., appropriately turned and positioned, moisture/incontinence managed)
The individual has used a group 2 or 3 support surface for pressure ulcers on the posterior trunk or pelvis (e.g., pressure reducing air mattress, air flotation bed, air-fluidized bed)
ANY ONE of the following:
High-volume drainage interfering with healing
Standard dressings cannot be maintained due to anatomic factors
Venous insufficiency ulcers when ALL of the following are met:
High-volume drainage interfering with wound healing
Wound has failed to heal after 90 days of optimal wound care that includes ALL of the following:
Compression bandages and/or garments have been consistently applied
Leg elevation and ambulation have been encouraged, or is not applicable
Wounds in individuals with an underlying clinical condition (i.e., diabetes, marasmus [protein/calorie malnutrition], small vessel disease, morbid obesity) that have failed to heal after 30 days of optimal wound care (e.g., appropriately turned and positioned, moisture/incontinence managed)
Traumatic or surgical wounds with ALL of the following:
Delayed primary closure
Exposed bone, cartilage, tendon, or foreign material within the wound
Continuation of powered negative pressure wound therapy is indicated when ALL of the following are met:
Completion of an initial 30 day therapeutic trial with documentation of ANY ONE of the following:
Development of granulation tissue
Decreasing wound size
Decreasing wound depth
Epithelial spread from the wound margins
ABSENCE of ALL of the following:
Necrotic tissue with eschar
Nonenteric and unexplored fistula
Malignancy in the wound
Exposed anastomotic site (communication between blood vessels)
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
Evidence from comparative clinical trials demonstrated that use of NPWT may provide a significant clinical benefit in a subset of problematic wounds. Due to clinical variability, it is not possible to determine prospectively which wounds are most likely to respond favorably to NPWT. For this reason, a thirty day therapeutic trial of NPWT is considered medically appropriate for chronic wounds that have failed to heal despite intense conventional wound therapy.
Current studies of a small number of individuals using the non-powered (mechanical) gauze-based NPWT system are insufficient to draw conclusions about its impact on net health outcome. Well-designed comparative studies with larger numbers of individuals are needed.
Acosta, S., Björck, M., & Petersson, U. (2017). Vacuum-assisted wound closure and mesh-mediated fascial traction for open abdomen therapy – a systematic review. Anaesthesiology Intensive Therapy, 49 (2), 139-145. Abstract retrieved June 26, 2017 from PubMed database.
Agency for Healthcare Research and Quality. (September, 2014). Report on negative pressure wound therapy technologies for chronic wound care in the home setting. Retrieved October 13, 2015 from http://www.ahrq.gov.
American College of Physicians. (2015). Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Retrieved June 25, 2018 from https://www.acponline.org/clinical-information/guidelines.
BlueCross BlueShield Association. Medical Policy Reference Manual. (1:2018). Negative pressure wound therapy in the outpatient setting. (1.01.16) Retrieved June 21, 2018 from BlueWeb. (46 articles and/or guidelines reviewed)
CGS Administrators, LLC. (2017, January). Local Coverage Article: Pressure reducing support surfaces - group 3 - policy article (A52468). Retrieved June 25, 2018 from www.cms.gov.
CGS Administrators, LLC. (2017, May). Local Coverage Article: Pressure reducing support surfaces - group 2 - policy article (A52490). Retrieved June 25, 2018 from www.cms.gov.
CGS Administrators, LLC. (2017, May). Local Coverage Determination: Negative pressure wound therapy pumps (L33821). Retrieved June 25, 2018 from www.cms.gov.
DeVries, F., Wallert, E., Solomkin, J., Allegranzi, B., Egger, M., Dellinger, E., & Boermeester, M. (2016). A systematic review and meta-analysis including GRADE qualification of the risk of surgical site infections after prophylactic negative pressure wound therapy compared with conventional dressings in clean and contaminated surgery. Medicine, 95 (36), e4673. Abstract retrieved June 26, 2017 from PubMed database.
Liu, S., He, C., Cai, Y., Xing, Q., Guo, Y., Chen, Z, et al. (2017). Evaluation of negative-pressure wound therapy for patients with diabetic foot ulcers: systematic review and analysis. Therapeutics and Clinical Risk Management, 13, 533-534. (Level 2 evidence)
National Institute for Health and Care Excellence. (2013, November). Negative pressure wound therapy for the open abdomen. Retrieved October 7, 2015 from: http://www.nice.org.uk/ipg467.
National Institute for Health and Care Excellence. (2014, April). Pressure ulcers: prevention and management. Retrieved June 25, 2018 from http://www.nice.org.uk/guidance/cg179
National Institute for Health and Care Excellence. (2015, August). Diabetic foot problems: prevention and management. Retrieved June 25, 2018 from http://www.nice.org.uk/guidance/ng19.
Reddy, V. S. (2016). Use of closed incision management with negative pressure therapy for complex cardiac patients. Cureus, 8 (2), e506. Abstract retrieved July 19, 2016 from PubMed database.
Tricco, A., Antony, J., Vafaei, A., Khan, P., Harrington, A., Cogo, E., et al. (2015). Seeking effective interventions to treat complex wounds: an overview of systematic reviews. BMC Medicine, 13, 89. (Level 1 evidence)
U. S. Food and Drug Administration. (2013, November). Center for Devices and Radiologic Health. 510(k) Premarket Notification Database. K132741. Retrieved October 7, 2015 from http://www.fda.gov.
Winifred S. Hayes, Inc. Medical Technology Directory. (2016, December; last update search December 2017). Negative pressure wound therapy for chronic wounds: home use. Retrieved June 26, 2017 from www.Hayes.com/subscribers. (75 articles and/or guidelines reviewed)
ORIGINAL EFFECTIVE DATE: 11/18/2015
MOST RECENT REVIEW DATE: 11/29/2018
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
This document has been classified as public information.