12/02/2021    PM News Subscriber

Extension for Wound VAC Use

My patient is a type I diabetic with a chronic,
tunneling wound at the right foot. MRSA
osteomyelitis is present at the location. The
patient is blind and requires dialysis. They are
wheelchair bound and ambulation is impossible. We
have diminished the MRSA infection with the use of
a wound vacuum assisted closure (VAC) device,
heretofore paid for by Medicare. According to the
VAC device company, Medicare has a rule they will
continue to pay for only four months. Neither I nor
her PCP can determine how long that she has to
heal. The wound VAC device has allowed her to
remain in her home. She has actually regained her
appetite and has a fairly happy life with the
assistance of caregivers. I would appreciate any
advice on getting an extension from Medicare to use
the VAC device.

PM News Subscriber

Response: ince this post addresses the use of a
wound vacuum assisted closure device (ie. Wound
VAC) and the health insurance carrier appears to be
Traditional Medicare, it is important to access the
LCD that provides the most specific and correct
information regarding the appropriate use and the
correct billing for this device. Since the VAC
device is classified as Durable Medical Equipment
or DME, whether the Durable Medical Equipment
Regional Carrier is CGS Administrators, LLC or
Noridian Healthcare Solutions, LLC, the LCD that
needs to be accessed is L33821 Negative Pressure
Wound Therapy Pumps and the associated article
A52511 – Negative Pressure Wound Therapy Pumps –
Policy Article.

When you access the LCD and look under “Coverage
Indications, Limitations, and/or Medical
Necessity,” specifically under “WHEN COVERAGE
ENDS,” the following information is listed:
“For wounds and ulcers described under A or B
above, a NPWT pump and supplies will be denied as
not reasonable and necessary with any of the
following, whichever occurs earliest:
1. Criteria C1-C2 cease to occur,
2. In the judgment of the treating practitioner,
adequate wound healing has occurred to the degree
that NPWT may be discontinued,
3. Any measurable degree of wound healing has
failed to occur over the prior month. Wound healing
is defined as improvement occurring in either
surface area (length times width) or depth of the
wound
*4. 4 months (including the time NPWT was applied
in an inpatient setting prior to discharge to the
home) have elapsed using a NPWT pump in the
treatment of the most recent wound
5. Once equipment or supplies are no longer being
used for the beneficiary, whether or not by the
treating practitioner’s order”

The point here is that the “VAC device company” was
correct in that Medicare does indeed have a rule
that they will only continue to pay for the NPWT
pump and supplies based upon #4 above. The big
question is: Can an extension to the 4 month time
frame for the NPWT pump and supplies be obtained?
In order to address this issue, you need to access
the associated article A52511 – Negative Pressure
Wound Therapy Pumps – Policy Article. POLICY
SPECIFIC DOCUMENTATION REQUIREMENTS needs to be
accessed. The following information is found:

“When NPWT therapy exceeds 4 months on the most
recent wound and reimbursement ends, individual
consideration for one additional month at a time
may be sought using the appeals process.
Information from the treating practitioner’s
medical record, contemporaneous with each requested
one-month treatment time period extension, must be
submitted with each appeal explaining the special
circumstances necessitating the extended month of
therapy.” Note, the LCD provides coverage for the
use of NPWT limited to initiating healing of the
problem wounds described in the “Coverage
Indications, Limitations and/or Medical Necessity”
section of the related LCD rather than continuation
of therapy to complete healing since there is no
published medical literature demonstrating evidence
of a clinical benefit for the use of NPWT to
complete wound healing. Therefore, general, vague
or nonspecific statements in the medical record
such as “doing well, want to continue until healed”
provide insufficient information to justify the
need for extension of treatment. The medical record
must provide specific and detailed information to
explain the continuing problems with the wound,
what additional measures are being undertaken to
address those problems and promote healing and why
a switch to alternative treatments alone is not
possible.

This is not my opinion. These are the rules.

Michael G. Warshaw, DPM, CPC, Lady Lake, FL

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