CG-DME-48 Vacuum Assisted Wound Therapy in the Outpatient Setting

This policy addresses outpatient vacuum-assisted wound therapy (negative pressure wound therapy/NPWT) devices. It is covered as medically necessary only when all criteria are met as part of a complete wound care program: documented clinician evaluation and wound measurements, use of moisture-retentive dressings, debridement of necrotic tissue, assessment/provision of adequate nutrition, and appropriate management of underlying conditions; typical indications include pressure ulcers, neuropathic/vascular ulcers, dehisced wounds, and select surgical wounds needing enhanced granulation. NPWT is not medically necessary when continuation criteria are not met, for any use that does not meet the above medical necessity criteria, or for routine prophylactic use in the postoperative setting.

"Vacuum assisted wound therapy is consideredmedically necessarywhen the individual meetsallof the criteria (A, B, and C) below:"