Get the free Vacuum Assisted Wound Closure Device Coverage Extension Request Form

This form is used to request continued coverage for a Vacuum Assisted Wound Closure Device and outlines the criteria that must be met for approval.

How to fill out vacuum assisted wound closure

How to fill out Vacuum Assisted Wound Closure Device Coverage Extension Request Form

1. Obtain the Vacuum Assisted Wound Closure Device Coverage Extension Request Form from your healthcare provider or insurance company.
2. Fill in your personal information, including your name, date of birth, and insurance policy number at the top of the form.
3. Provide details about the wound needing treatment, including diagnosis, date of injury, and any previous treatments attempted.
4. Specify the type of Vacuum Assisted Wound Closure Device being requested and include the manufacturer's name and model if applicable.
5. Include the physician’s information, including name, specialty, and contact details.
6. Attach supporting medical documentation, such as physician notes, treatment history, and images of the wound as required.
7. Review the completed form for accuracy and completeness.
8. Submit the form and attached documents to your insurance company or designated department.
9. Follow up with your insurance provider to confirm receipt and check the status of your request.

Who needs Vacuum Assisted Wound Closure Device Coverage Extension Request Form?

1. Patients with chronic or non-healing wounds that require the use of a Vacuum Assisted Wound Closure Device.
2. Healthcare providers seeking coverage for the use of Vacuum Assisted Wound Closure Devices in their patients.
3. Individuals appealing a denial for coverage of such devices based on prior claims or treatments.

People Also Ask about

How to apply vacuum-assisted closure?

A foam or gauze dressing is put directly on the wound. An adhesive film covers and seals the dressing and wound. A drainage tube leads from under the adhesive film and connects to a portable vacuum pump. This pump removes air pressure over the wound, along with any fluids that drain from the wound.

What is the full form of VAC closure?

Vacuum assisted closure of a wound is a type of therapy or dressing to help wounds heal. It is also known as 'a VAC' or 'negative pressure wound therapy' (NPWT). The VAC system has several parts to it. During treatment, a special foam or gauze dressing is placed directly onto the wound.

Can you bill for a wound vac application?

CPT Code 97605 is used for negative pressure wound therapy (NPWT), a specialized wound care treatment involving a vacuum-assisted closure (VAC) device. This code applies to wounds treated with NPWT using a durable medical equipment (DME) system and a wound surface area of less than or equal to 50 square centimeters.

When is a wound vac no longer needed?

In the presence of persistent infection or deterioration, or in wounds exhibiting no clinical progress towards healing (i.e. odour continues or becomes apparent), perform a thorough patient and wound reassessment (including microbiological investigations), discontinue VAC therapy and change treatment.

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What is Vacuum Assisted Wound Closure Device Coverage Extension Request Form?

The Vacuum Assisted Wound Closure Device Coverage Extension Request Form is a document used to request extended coverage for the use of vacuum assisted wound closure devices in wound care treatments.

Who is required to file Vacuum Assisted Wound Closure Device Coverage Extension Request Form?

Healthcare providers or facilities that utilize vacuum assisted wound closure devices for patient treatment are required to file this form to seek coverage extension from insurance providers.

How to fill out Vacuum Assisted Wound Closure Device Coverage Extension Request Form?

To fill out the form, providers should enter patient information, details of the wound, treatment provided, the necessity for extended coverage, and any supporting medical documentation as required by the insurance payer.

What is the purpose of Vacuum Assisted Wound Closure Device Coverage Extension Request Form?

The purpose of the form is to formally request insurance coverage for the continued use of vacuum assisted wound closure devices beyond initial authorization periods.

What information must be reported on Vacuum Assisted Wound Closure Device Coverage Extension Request Form?

The form must report patient demographics, medical history, details of the wound type and treatment plan, previous coverage statements, and any clinical justification for the need for continued use of the device.