Negative Pressure Wound Therapy Vacuum-Assisted Closure

ConnectCare covers negative pressure wound therapy (NPWT) or vacuum assisted closure (VAC) for nonhealing wounds when any of the following conditions exist:

1. There are complications of a surgically created wound (e.g. dehiscence, poststernotomy disunion with exposed sternal bone, poststernotomy mediastinitis, or postoperative disunion of the abdominal wall).

2. NPWT is initiated because it is considered in the judgement of the treating physician, the best option in the treatment of wounds from acute injury (eg, trauma, burns, surgical debridement) and open abdomen.

3. There is 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.

4. There is a chronic, non-healing 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), documented maintenance of an adequate nutritional status, and weekly evaluations with documentation of wound measurements (i.e. length, width, and depth) in one of the following clinical situations:
   1. Chronic Stage III or Stage IV pressure ulcer:

                                          i.    The patient has been on an appropriate turning and repositioning regimen.

                                         ii.    The patient has used an appropriate pressure relief device (e.g. low air loss bed, alternating pressure mattress) for pressure ulcers on the posterior trunk or pelvis.

                                        iii.    The patient’s moisture and incontinence have been appropriately addressed.

                                        iv.    Stasis ulcer treatment as long as there is any evidence of healing or no evidence of worsening.

4. 2. Chronic diabetic neuropathic ulcer:

                                          i.    The patient has been on a comprehensive diabetic management program.

                                         ii.    The patient has had appropriate foot care.

                                        iii.    The patient has been non-weight bearing if appropriate.

4. 3. Chronic venous ulcer:

                                          i.    Compression garments/dressings have been consistently applied.

                                         ii.    Leg elevation and ambulation have been encouraged.

5. When NPWT is used to provide skin graft/flap fixation to improve skin graft success.

ConnectCare does not cover NWPT or VAC for nonhealing wounds or ulcers under the following conditions because medical necessity or efficacy has not been established:

• An appropriate medical professional is not supervising or performing weekly wound measurement and assessment functions, and negative pressure wound therapy dressing changes are required.
• Wound healing has occurred to the extent that negative pressure wound therapy is no longer necessary.
• The depth of the wound is less than 1 mm, as wounds of this depth cannot accommodate the sponge.
• Uniform granulation tissue has been obtained.
• The patient cannot tolerate the use of NPWT.
• The wound is infected, and requires surgical debridement of non-viable tissue.

There is no progression of healing of the wound as determined by wound measurement and description over the time span of one month.

Approved:  6/08

Reviewed: 1/09, 2/11, 1/12, 3/14, 1/15, 1/16, 1/17, 1/18, 1/19, 2/20

Revised: 3/10, 1/13, 1/15, 1/16