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Negative Pressure Wound Therapy (NPWT) / Vacuum-Assisted Wound Closure Therapy (V.A.C.)

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative process

Prior authorization is not required for negative pressure wound therapy (NPWT)/vacuum-assisted wound closure therapy (VAC).

NPWT/VAC is generally covered subject to the indications listed below, and per your plan documents.

Indications that are covered

NPWT is covered for the following indications:

  1. For the following non-healing wounds when other treatments have not proven effective:
    1. Chronic open wounds (stasis ulcer, diabetic ulcer, pressure ulcer and arterial insufficiency ulcers);
    2. Dehisced incisions;
    3. Flaps;
    4. Skin grafts
  2. Additional covered items used with the VAC® unit are:
    1. Canister pack with collection bottle, tubing/clamp, adapter (changed daily)
    2. Foam dressing kit with tubing, drapes, transparent dressing (changed every 12 to 48 hours)

Vacuum-assisted closure (V.A.C.) system of NPWT consists of a foam dressing with a connecting tube placed into the wound space. A transparent dressing is used to seal the foam dressing and tubing which then compresses when negative pressure is applied. A controlled vacuum, created by a computerized vacuum pump, is applied to the wound continuously or cyclical. It is attached to a canister to collect the secretions. It is a re-usable device.

PICO NPWT system: A single-use negative pressure wound therapy system for use in the hospital and at home for treatment of a variety of chronic, acute, traumatic, and surgical wounds.  According to the company’s website, Pico is a single-use pocket-sized device intended to deliver NPWT. The Pico system by design ceases to function after seven days of therapy.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Prior authorization is not required for the following codes:

A6550 – Wound care set, for negative pressure wound therapy electrical pump, includes all supplies
and accessories

A9272 - Wound suction, disposable, includes dressing, all accessories and components, any type, each

E2402 - Negative pressure wound therapy electrical pump, stationary or portable

G0456 - Negative pressure wound therapy,(e.g. vacuum assisted drainage collection) using a
mechanically-powered device, not durable medical equipment, including provision of cartridge
and dressing(s), topical application(s), wound assessment, and instructions for ongoing care,
per session; total wound(s) surface area less than or equal to 50 square centimeters

G0457 - Negative pressure wound therapy,(e.g. vacuum assisted drainage collection) using a
mechanically-powered device, not durable medical equipment, including provision of cartridge
and dressing(s), topical application(s), wound assessment, and instructions for ongoing care,
per session; total wound(s) surface area greater than 50 sq cm

97605 – Negative pressure wound therapy (eg, vacuum assisted drainage collection), including topical
application(s), wound assessment, and instruction(s) for ongoing care, per session; total
wound(s) surface area less than or equal to 50 square centimeters

97606 – Negative pressure wound therapy (eg, vacuum assisted drainage collection), including topical
application(s), wound assessment, and instruction(s) for ongoing care, per session; total
wound(s) surface area greater than 50 square centimeters

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Vendor

For in-network benefits to apply, item must be received from a contracted vendor or provider.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

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Policy activity

  • 7/14/1998 - Date of origin
  • 7/14/1998 - Effective date
Reviews & revisions
  • 1/2015
Policy number
  • D064-05

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