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24.5.14.7 Prior Authorization
To request prior authorization for a wound system, the documentation listed below must be provided on the Statement of Initial Wound Therapy System In-Home Use Form on page B-91 for an initial or recertification request and submitted with the signed and dated Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form. The original documentation must be maintained by the prescribing physician in the client's medical record. A copy of these documents must be maintained by the requesting provider.
• Accurate diagnostic information pertaining to the underlying diagnosis/condition and any other medical diagnoses/conditions, including the client's overall health status.
•The client's use of a pressure reducing mattress, when appropriate.
•Albumin level within the last 30 days:
•If the albumin level is below 3.0, documentation must show that nutritional supplement is in place.
•Hemoglobin A1c obtained within last 30 days if the client has a diagnosis of diabetes mellitus.
•Appropriate medical history related to the current wound:
•Documentation that the wound is free of necrotic tissue and infection, or if infection is present, that it is being treated with antibiotics, including the name of the antibiotic, dosage, frequency, and route of administration.
•Wound measurements to include length, width, and depth, any tunneling and/or undermining.
•For recertification, documentation that the wound is improving.
•Wound color, drainage (type and amount), and odor if present.
•The prescribed wound care regimen, to include frequency, duration, and supplies needed.
•Identification of the caregiver who agrees to be available to assist client during this time and agreement of this person not to operate the negative pressure or the pulsatile jet irrigation system if used.
•Documentation that an RN who is certified in the use of the wound care system is performing the wound care when a negative pressure or pulsatile jet irrigation wound care system is used. All requirements for skilled nursing care must be met.
Wound care system supplies are limited to a maximum of:
•15 dressing kits or supplies per wound per month unless documentation supports that the wound size requires more than one dressing kit for each dressing change or if the physician has ordered more frequent dressing changes.
When documentation supports evidence of high-volume drainage, defined as greater than 90 ml per day, a stationary pump with the largest capacity canister must be used. Extra canisters related to the equipment failure are not considered medically necessary.
Wound care systems and related supplies will not be prior authorized nor considered for reimbursement when:
•The client has one of the following contraindications:
•A fistula to the body.
•Wound ischemia.
•Gangrene.
•Skin cancer in the wound margins.
•Presence of necrotic tissue, including bone (nonapplicable to the pulsatile jet irrigation wound care system).
•Osteomyelitis (unless it is being treated; the treatment must be identified).
•Less than six months to live.
•In the documented judgement of the treating physician, adequate wound healing has occurred and the wound care system is no longer required.
•No measurable wound healing has occurred over the previous 30-day period.
•A wound care system was used for four months or more in the inpatient setting before discharge, except when documentation supports continued significant improvement in wound healing.
•The wound care equipment and supplies are no longer being used by the client. Stand-by use equipment and supplies are not a benefit of Home Health Services.
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