The member has used a group 2 or 3 support surface for pressure ulcers on the posterior trunk or pelvis (see CPB 0430 - Pressure Reducing Support Surfaces) Note: A group 2 or 3 support surface is not required if the ulcer is not on the trunk or pelvis and.The member has been appropriately turned and positioned, and.Evaluation of and provision for adequate nutritional status.Documentation of evaluation, care, and wound measurements by a licensed medical professional, and.Debridement of necrotic tissue if present, and.Application of dressings to maintain a moist wound environment, and.General measures of wound therapy programįor all ulcers or wounds, the following components of a wound therapy program must include a minimum of all of the following general measures, which should either be addressed, applied, or considered and ruled out prior to application of NPWT:.A complete wound therapy program described by criterion A and criterion B, C, or D below, as applicable depending on the type of wound, has been tried or considered and ruled out prior to application of NPWT. The member has a chronic Stage III or IV pressure ulcer (see Appendix below), neuropathic ulcer (e.g., diabetic ulcer), venous or arterial insufficiency ulcer, or a chronic ulcer of mixed etiology, present for at least 30 days. This Clinical Policy Bulletin addresses negative pressure wound therapy.Īetna considers negative pressure wound therapy (NPWT) pumps medically necessary, when either of the following criteria (I or II) is met: Number: 0334 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References
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