Coverage of Conditions and Treatments (Coverage Decisions)
Use this lookup tool to determine coverage decisions, or if prior authorization is needed for the treatment or condition. Note: For Self-insured employer claims, you must contact the employer or their claims administrator.
List also available in PDF format.
See Treatment Guidelines and Resources for additional information.
Negative pressure wound therapy (NPWT) involves the application of subatmospheric pressure to a wound to remove exudate and debris with the goal of facilitating wound healing, promoting granulation of the wound bed, and providing a bridge to surgical closure.
Conditions of Coverage
A complete wound therapy program must have been tried and failed prior to NPWT or the complete wound therapy programs are contraindicated.
Discontinuation of coverage
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, OR
Four months (including the time NPWT was applied in an inpatient setting prior to discharge to the home) have elapsed using an NPWT pump in the treatment of the most recent wound.
Treatment is not covered in patients with contraindications referred to by the FDA Safety Communication dated February 24, 2011. Contraindicated for these wound types/conditions:
- Necrotic tissue with eschar present
- Untreated osteomyelitis
- Non-enteric and unexplored fistulas
- Malignancy in the wound
- Exposed vasculature
- Exposed nerves
- Exposed anastomotic site
- Exposed organs
Note: For all ulcers or wounds, appropriate standard forms of treatment should be applied prior to application of NPWT. The nursing staff caring for the injured worker must complete the Preauthorization & Continued Authorization Request Form.
This technology was reviewed by the State Health Technology Clinical Committee (HTCC) in November 2016 and the determination was finalized on January 20, 2017. The committee’s determination, based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, is that NPWT is a covered benefit with conditions. Complete information on this HTCC determination is available at: What we're working on | Washington State Health Care Authority.
In adopting this HTCC coverage determination, the Department has concluded that the determination does not conflict with any state statute. Any coverage for investigational treatment would be considered per WAC 296-20-02850. Any coverage for health technologies that have a FDA Humanitarian Device Exemption status would be considered per RCW 70.14.120 (1) (b).
Implementation of the Coverage Decision
All requests for NPWT require prior authorization. The service may be covered only for care of a condition accepted on or related to the claim.