Negative Pressure Wound Therapy (NPWT) for the Treatment of Wounds

This policy covers negative pressure wound therapy (NPWT)—including electrically powered non-disposable devices and select non-powered disposable systems—when used as part of a wound therapy program for acute wounds (<30 days) and chronic wounds (≥30 days) such as traumatic/surgically created wounds with failed closure, chronic Stage 3–4 pressure ulcers, diabetic neuropathic ulcers, and venous/arterial or mixed etiology ulcers and patients with comorbidities that impair healing. Coverage requires prior/concurrent measures (moist dressings, debridement if present, adequate nutrition, weekly wound measurements), documented lack of improvement for chronic wounds, clinician assessment with biweekly documentation for continued use, adherence to size/exudate limits (1–100 cm², widest diameter <10 cm, ≤150 cc/3 days), and excludes situations such as necrotic eschar, untreated osteomyelitis, malignancy, exposed vasculature/nerves/organs/anastomoses, non‑enteric unexplored fistulae, and other benefit plan or state rule restrictions.