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Date Printed: June 23, 2017: 11:41 AM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

09-E0000-42

Original Effective Date: 04/15/02

Reviewed: 04/22/10

Revised: 11/01/15

Subject: Non-Contact Radiant Heat Bandage for the Treatment of Wounds

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates  

DESCRIPTION:

An optimal environment for wound healing is believed to include a moist normothermic environment that functions in part to enhance the subcutaneous oxygen tension and increase the blood flow to the wound. The Warm-UpĀ® Active Wound Therapy is one of many normothermic wound therapy (NNWT) devices that attempt to create this type of environment. The device includes a non-contact bandage and a warming unit designed to maintain 100% relative humidity and to produce normothermia in the wound and surrounding tissues. The bandage is composed of a sterile foam collar that adheres to the skin around the wound and a sterile, transparent film that covers the top of the wound, but does not touch the wound. An infrared warming card is inserted into a pocket in the film covering. Treatments are typically administered three times per day in 1-hour sessions. This therapy is also known as non-contact non-contact radiant heat bandage wound therapy.

POSITION STATEMENT:

The use of non-contact radiant heat bandage (i.e., Warm-Up Active Wound Therapy) is considered experimental or investigational, as there is insufficient evidence in the peer-reviewed clinical literature to support effectiveness for treating wounds (e.g., chronic venous ulcers). Available published clinical studies were small in size and lacked long-term follow-up data.

BILLING/CODING INFORMATION:

HCPCS Coding

A6000

Non-contact wound warming wound cover for use with the non-contact wound warming device and warming card (investigational)

E0231

Non-Contact wound warming device (temperature control unit, AC adapter and power cord) for use with warming card and wound cover (investigational)

E0232

Warming card for use with the non-contact wound warming device and non-contact wound warming wound cover (investigational)

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Noncontact Normothermic Wound Therapy (270.2) located at cms.gov.

DEFINITIONS:

Normothermic: pertaining to or characterized by normal temperature; neither hyperthermic nor hypothermic.

RELATED GUIDELINES:

None applicable.

OTHER:

Other terms used to describe non-contact radiant heat bandage for the treatment of wounds:

Note: The use of specific product names is illustrative only. It is not intended to be a recommendation of
one product over another, and is not intended to represent a complete listing of all products available.

Normothermic wound therapy
Warm Up Active Wound Therapy
Wound therapy

REFERENCES:

  1. American Medical Association CPT Coding (current edition).
  2. Association for the Advancement of Wound Care (AAWC). Summary algorithm for venous ulcer care with annotations of available evidence. Malvern (PA): Association for the Advancement of Wound Care (AAWC); 2005. 25 p.
  3. Blue Cross Blue Shield Association Medical Policy 2.01.41 – Non-Contact Radiant Heat Bandage for the Treatment of Wounds (archived 07/09/09).
  4. Centers for Medicare and Medicaid Services (CMS), National Coverage Determination (NCD) Manual, Publication 100-3. Section 270.2, Noncontact Normothermic Wound Therapy (07/01/02).
  5. ECRI Custom Hotline Response, Noncontact Normothermic Wound Therapy (NNWT) for Chronic Wound Healing, (12/29/05 update to the above Target report).
  6. ECRI Institute Emerging Technology (TARGET) Evidence Report: “Noncontact normothermic wound therapy (NNWT) for chronic wound healing” (12/02).
  7. Frykberg RG, Zgonis T, Armstrong DG, Driver VR, Giurini JM, Kravitz SR, Landsman AS, Lavery LA, Moore C, Schuberth JM, Wukick DK, Andersen C, Vanore JV. Diabetic foot disorders: a clinical practice guideline. J Foot Ankle Surg. 2006 Sep-Oct;45(5):S2-66.
  8. Gawley B, Gould L, Evaluation of a Low Profile Noncontact Normothermic Wound Dressing for Split=Thickness Skin Graft Donor Site Healing. Wounds. 2006.
  9. Hayes Medical Technology Directory – "Warm-Up Active Wound Therapy For Wound Healing", (08/00) (Archived).
  10. Hayes Medical Technology Directory Update Report – “Warm-Up Active Wound Therapy for Wound Healing” (08/27/02) (archived).
  11. Hayes Medical Technology Directory. Noncontact Normothermic Wound Therapy for Chronic Ulcers. (08/06; updated 09/18/07).
  12. HCPCS Level II Coding (current edition).
  13. Thomas DR, Diebold MR, Eggemeyer LM. A Controlled, randomized, comparative study of a radiant heat bandage on the Healing of stage 3 – 4 pressure ulcers: A Pilot Study. J Am Med Dir Assoc., 2005 Jan-Feb.
  14. US Food and Drug Administration (FDA). The Warm-Up Active Wound Therapy device 510(k) approval March 28, 1997.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 04/22/10.

GUIDELINE UPDATE INFORMATION:

04/15/02

New Medical Coverage Guideline.

12/15/02

Medical Coverage Guideline re-numbered.

04/15/03

Reviewed; no changes in coverage.

04/15/04

Scheduled review; no changes in coverage.

04/15/05

Scheduled review; no change in coverage.

04/15/06

Scheduled review; no change in coverage statement; references updated.

04/15/07

Scheduled review; no change in coverage statement; references updated.

06/15/07

Reformatted guideline.

04/15/08

Scheduled review; no change in position statement, references updated.

05/15/09

Scheduled review; no change in position statement; references updated.

05/15/10

Scheduled review; position statement unchanged; references updated; formatting changes.

05/11/14

Revision: Program Exceptions section updated.

11/01/15

Revision: ICD-9 Codes deleted.

Date Printed: June 23, 2017: 11:41 AM