Negative Pressure Wound Therapy - DME.SW.105.A

Evicore covers rental of NPWT pumps (HCPCS E2402) and supplies (A6550, A7000) for acute surgical/traumatic wounds and specified non‑healing chronic wounds (stage 3–4 pressure injuries, diabetic, venous, arterial, and other complex wounds) but excludes use with untreated osteomyelitis, necrotic tissue without debridement, malignant wounds, fistulae to organs, exposed vital structures, pediatric use (not established), and single‑use disposable NPWT devices. Coverage requires documented prior conservative wound care (assessment/measurements, appropriate dressings, debridement if needed, treatment of infection/underlying conditions), an initial 30‑day rental with 30‑day renewals contingent on monthly wound measurements and demonstrated progress, limits of ≤15 A6550/wound/month and ≤10 A7000/month unless justified, and additional monthly justification if use exceeds four months.

"A negative pressure wound therapy (NPWT) pump (HCPCS E2402) and supplies (HCPCS A6550, A7000) are indicated for an acute surgical (e."