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LCD - Wound Pump

Coverage Summary

  1. Completed Written Order Prior to Delivery
  2. Medical record documentation: A Negative Pressure Wound Therapy pump and supplies are covered when either criterion A OR B is met:

  • A. Ulcers and Wounds in the home setting:
    The patient has a chronic Stage III or IV pressure ulcer, neuropathic (for example, diabetic) ulcer, venous or arterial insufficiency ulcer, or a chronic (being present for at least 30 days) ulcer of mixed etiology. A complete wound therapy program must have been tried or considered and ruled out prior to application of Negative Pressure Wound Therapy.

  • B. Ulcers and Wounds encountered in an inpatient setting:
  1. An ulcer or wound is encountered in the inpatient setting and, after wound treatments described have been documented as tried or considered and ruled out, Negative Wound therapy is initiated because it is considered in the judgment of the treating physician, the best available treatment option.
  2. The patient has complications of a surgically created wound (for example, dehiscence) or a traumatic wound (for example, pre-operative flap or graft) where there is documentation of the medical necessity for accelerated formation of granulation tissue which cannot be achieved by other available topical wound treatments (for example, other conditions of the patient that will not allow for healing times achievable with other topical wound treatments).

Order Requirements

  1. Patient Name
  2. Specific description of ordered items to be delivered (ie, Wound Pump, Dressing Kits, Cannisters, Tubing)
  3. Wound pump setting
  4. Item quantity to be dispensed
  5. Wound pump setting and prescribed dressing changes (quantity and frequency)
  6. Frequency of use
  7. Length of Medical Need (ie, lifetime or other)
  8. Ordering Physician's NPI
  9. Ordering physician’s legible signature (personally written or electronically signed by the physician, stamps are not accepted by insurance).
  10. Ordering physician’s legible signature date (personally written or electronically signed by the physician, stamps are not accepted by insurance).
  11. Start date of the order – if different than the Physician's signature date.

Coverage Detail

  • Click on "Documentation Reference" to display a medical documentation reference form. The reference form is a supplier generated form and cannot be used as part of the medical record. The form is provided in order to assist in gathering the documentation that must be in the medical record.

Negative Wound Pump and supplies are covered when the wound was encountered in the Home, or Inpatient Setting, and applicable measures have been tried and/or considered and ruled out:

Diagnosis for wounds encountered in the home setting:

  • Stage III and IV pressure ulcers
  • Neuropathic (diabetic) ulcers
  • Venous insufficiency ulcers(flow of blood to heart is impaired)

Diagnosis for wounds encountered in an inpatient setting:

  • Surgically created wounds
  • Stage III and IV pressure ulcers
  • Neuropathic (diabetic) ulcers
  • Venous insufficiency ulcers (flow of blood to heart is impaired)

Prior to application of the NPWT, the scenarios below must have been tried or considered and ruled out for all ulcers and wounds:
  • Documentation of evaluation, care, and wound measurements by a licensed medical professional, and
  • Application of dressings to maintain a moist wound environment, and
  • Debridement of necrotic tissue if present, and
  • Evaluation of and provision for adequate nutritional status

Stage III and IV pressure ulcers

  • The patient has been appropriately turned and positioned, and
  • A group 2 or 3 support surface has been used, and
  • The patient's moisture and incontinence have been appropriately managed

Neuropathic ulcers

  • The patient has been on a comprehensive diabetic management program, and
  • Pressure reduction has been accomplished (Foot Ulcer)

Venous insufficiency ulcers

  • Compression bandages and /or garments have been consistently applied and
  • Leg elevation and ambulation have been encouraged

Surgically Created

  • Complications such as dehiscence, pre-operative flap or graph, where accelerated formation of granulation of tissue cannot be achieved by other topical wound treatments. (wound is not healing in a timely manner)

Exclusions from Coverage
  • The presence of necrotic tissue with eschar(without debridement)
  • Osteomyelitis(infection of the Bone) within the vicinity of the wound(not being treated separately)
  • Cancer in the wound
  • Open Fistula to an organ or body cavity (within the vicinity of the wound)

Monthly Supply Limitations
Additional documentation needed for any supplies over these limits. If additional supplies requested are not related to medical need, patient must sign an ABN (or Non-Medicare ABN) and private pay.

  • Pump rental, on a normal basis, is covered up to 4 months (including inpatient use).
  • (15) dressing sets
  • (10) canisters (Additional canisters may be covered but drainage must be more than 90 ml per day and this must be documented with Dr. signature and date.)
  • (4) tubing sets