This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions


This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to persons covered by the Mississippi Children's Health Insurance Program, Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions


This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to persons covered by the Mississippi Children's Health Insurance Program, Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions

Medical Policy Search
Printer Friendly Version Vacuum-Assisted Closure of Chronic Wounds

Vacuum-Assisted Closure of Chronic Wounds

 

DESCRIPTION

 The management and treatment of chronic wounds, including decubitus ulcers, remain a treatment challenge. Most chronic wounds will heal only if the underlying cause, i.e., venous stasis, pressure, infection, etc. is addressed. In addition, cleaning of the wound to remove non-viable tissue, microorganisms, and foreign bodies is essential to create the optimal conditions for either reepithelialization (i.e., healing by secondary intention to create the optimal conditions for either re-epithelialization (i.e., healing by secondary intention) or preparation for wound closure with skin grafts, or flaps (i.e., healing by primary intention). Therefore, debridement, irrigation, whirlpool treatments, and wet-to-dry dressings are common components of chronic wound care.

Vacuum-assisted closure is a new technique designed to promote the formation of granulation tissue in the wound bed either as an adjunct to surgical therapy, or as an alternative to surgery in a debilitated patient. In this system, a special foam dressing with an attached evacuation tube is inserted into the wound and covered with an adhesive drape in order to create an airtight seal. Negative pressure is then applied and the wound effluent is collected in a canister. Although the exact mechanism has not been elucidated, it is hypothesized that negative pressure contributes to wound healing by removing excess interstitial fluid, increasing the vascularity of the wound, and/or creating beneficial mechanical forces that draw the edges of the wound closer together.

The V.A.C.® system is an FDA-approved device for vacuum assisted closure of wounds. This device was designed to be used in-patient, skilled nursing facilities or in the home.

 

POLICY

 Vacuum-assisted closure of chronic wounds is considered investigational.

 

POLICY EXCEPTIONS

 State Health Plan (State and School Employees): Refer to the Member's Plan for benefits, limitations, and/or exclusions for this procedure.

 

POLICY GUIDELINES

 Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

 

POLICY HISTORY

 4/1997: Approved by Medical Policy Advisory Committee (MPAC)

5/2000: Reviewed by MPAC; investigational status maintained

2/12/2002: Investigational definition added

2/19/2002: HCPCS K0538, K0539, K0540 non-covered codes added

5/10/2002: Type of Service and Place of Service deleted

9/20/2002: Policy reviewed, Sources updated

11/20/2003: Reviewed by MPAC, investigational status changed to medically necessary in patients with pressure ulcers, venous/vasculitic ulcers, dehisced wounds (wounds with exposed orthopedic hardware or bone), acute wounds, or poststernotomy mediastinitis, assuming that it is used after all standard treatment options have failed and as an adjunct to standard treatment, FEP exception added, HCPCS K0538, K0539, K0540 moved to covered

2/16/2004: Code Reference section updated, HCPCS A6550, A6551, E2402 added covered codes 

3/25/2004: Reviewed by MPAC, medically necessary status changed to investigational, FEP exception deleted, Code Reference section changed to non-covered, ICD-9 diagnosis codes 519.2, 707.0, 707.10, 707.11, 707.12, 707.13, 707.14, 707.15, 707.19, 707.8, 707.9, 998.32 and “For acute wounds, see the open wound code range” deleted, HCPCS A6550, A6551, E2402, K0538, K0539, K0540 moved to non-covered, HCPCS K0538, K0539, K0540 deletion date of 12/13/2003 added 

3/31/2004: Code Reference section reviewed, no changes

9/10/2004: Coding Reference section reviewed, no changes

2/18/2005: Policy reviewed, Sources updated

3/22/2005: Code Reference section updated, CPT code 97605, 97606 added non-covered codes, HCPCS K0538, K0539, K0540 deleted non-covered codes

3/15/2006: Coding updated.  HCPCS 2005 & 2006 revisions added to policy

1/10/2008: Policy reviewed, no changes

03/30/2011: State Health Plan verbiage added to the Policy Exceptions section. Removed deleted code A6551 from the Code Reference section.

12/21/2012:  Added the following new 2013 CPT codes to the Code Reference section: G0456  and G0457.

 

SOURCE(S)

 Hayes Medical Technology Directory

TEC, Volume 15, #25, March 2001

Blue Cross Blue Shield Association policy # 1.01.16

Samson, D., Lefevre, F., & N. Aronson. Wound-Healing Technologies: Low-Level Laser and Vacuum-Assisted Closure. Agency for Healthcare Research and Quality; Evidence Report/Technology Assessment. Number 111, pages 1-5.

 

CODE REFERENCE

 This is not an all-inclusive list of non-covered procedure codes.

All codes billed for this procedure are considered investigational and not eligible for coverage.

Non-Covered Codes

Code Number

Description

CPT-4

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 (effective 1-1-2005) 

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 (effective 1-1-2005) 

ICD-9 Procedure

ICD-9 Diagnosis

 

 

HCPCS

A6550

Wound care set for negative pressure wound therapy electrical pump, includes all supplies and accessories (effective 1-1-2004)  (moved to non-covered 3-25-2004) (revised 1-1-2006) 

E2402

Negative pressure wound therapy electrical pump, stationary or portable (effective 1-1-2004) (moved to non-covered 3-25-2004)

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 wounds(s) surface area less than or equal to 50 square centimeters (New 01-01-2013)

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 wounds(s) surface area greater than 50 square centimeters (New 01-01-2013)

 

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