REVIEW REQUEST FOR
Vacuum Assisted Wound Therapy in the
Outpatient Setting
Provider Data Collection Tool Based on Coverage Guideline DME.00009
Policy Last Review Date: 08/06/2015 / Policy Effective Date: 10/06/2015 / Provider Tool Effective Date: 10/06/2015Individual’s Name: / Date of Birth:
Insurance Identification Number/HCID: / Individual’s Phone Number:
Ordering Provider Name & Specialty: / Provider ID Number:
Office Address:
Office Phone Number: / Office Fax Number:
Rendering Provider Name & Specialty: / Provider ID Number:
Office Address:
Office Phone Number: / Office Fax Number:
Date/Date Range of Service: / Place of Service: Home Inpatient
Outpatient Other:
Service Requested (CPT/HCPCS if known):
Diagnosis Code(s) (if known):
This medical policy based, data collection tool is for a medical necessity request for use of vacuum assisted wound therapy (also known as negative pressure wound therapy or NPWT) in the outpatient setting for a variety of wounds, such as ulcers related to pressure sores, venous or arterial insufficiency or neuropathy.
Please check all that apply to the individual:
Initial Request
The request is for the initiation of electrically powered vacuum assisted wound therapy in the outpatient setting
The request is for the initiation of non-electrically powered vacuum assisted wound therapy
(for example, SNaPTM Wound Care Device) in the outpatient setting
The request is for a portable, battery-power, single use (disposable vacuum assisted wound therapy device
(for example, the PICOTM Single Use Negative Pressure Wound Therapy System or the V.A.C.® ViaTM
Negative Pressure Wound Therapy System)
Individual is 12 years of age or older
A complete wound care program has been tried
(check all that apply and complete the requested information):
Individual’s medical record documents wound evaluation, care and wound
measurements bya licensed medical professional (Provide the following wound information)
Location of wound:
Wound measurements (cm):
Application of dressings to maintain a moist environment
Debridement of necrotic tissue, if present
Evaluation of and provision for adequate nutritional status
(please specify interventions, if applicable):
Underlying medical conditions ( for example, diabetes, venous insufficiency, etc.) are being
appropriately managed
Other:
The individual has any of the following conditions: (check all that apply)
Pressure ulcers -Stage III or Stage IV(If checked, complete below)
Individual has been appropriately turned and positioned
Individual has used a group 2 or 3 support surface for pressure ulcers on the posterior trunk or
pelvis (no special support is required for ulcers not located on the trunk or pelvis)
Individual’s moisture and incontinence have been appropriately managed
Neuropathic ulcers (If checked, complete below)
Individual has been on a comprehensive diabetic management program
Reduction in pressure on a foot ulcer has been accomplished with appropriate modalities
Ulcers related to venous or arterial insufficiency (If checked, complete below)
Compression bandages and/or garments have been consistently applied
Reduction in pressure on a foot ulcer has been accomplished with appropriate modalities
The request is for initiation of treatment in the home setting and the ulcer has been present for
at least 30 days
Dehisced wounds or wounds with exposed hardware or bone
Post-sternotomy wound infection or mediastinitis
Complications of a surgically created wound where accelerated granulation therapy is necessary and
cannot be achieved by other available topical wound treatment
Other:
The wound to be treated is free from all of the following absolute contraindications to vacuum assisted wound
therapy (Please mark any of the following conditions that are present in the wound.)
Exposed anastomotic site
Exposed nerves
Exposed organs
Exposed vasculature
Malignancy in the wound
Necrotic tissue with eschar present
Non-enteric and unexplored fistulas
Untreated osteomyelitis
Continuation Request
Request is for continued use of electrically powered vacuum assisted wound therapy in the outpatient setting
Documentation of the weekly assessment of the wound(s) dimensions and characteristics by a licensed
healthcare professional:
Date Wound measurements (cm) Wound characteristics
Date Wound measurements (cm) Wound characteristics
Date Wound measurements (cm) Wound characteristics
Date Wound measurements (cm) Wound characteristics
Progressive wound healing is being demonstrated
Other:
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan or its designees may perform a routine audit and request the medical documentation to verify the accuracy of the information reported on this form.
______
Name and Title of Provider or Provider Representative Completing Form and Attestation (Please Print)* Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization management services on behalf of your health benefit plan or the administrator of your health benefit plan.
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