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DESCRIPTIONThe 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.
POLICYVacuum-assisted closure of chronic wounds is considered investigational.
POLICY EXCEPTIONSState Health Plan (State and School Employees): Refer to the Member's Plan for benefits, limitations, and/or exclusions for this procedure.
POLICY GUIDELINESInvestigative 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 HISTORY4/1997: 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 REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.