Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for negative pressure wound therapy, utilizing durable medical 
equipment, including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; 
total wound(s) surface area less than or equal to 50 square centimeters provided on May 7, 2022. 
 
You asked the Plan to pay for negative pressure wound therapy, utilizing durable medical equipment, including 
topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) 
surface area less than or equal to 50 square centimeters. The Plan denied your request. The Plan says the 
documentation provided does not support the use of negative pressure wound therapy. The documentation 
states a wound vac was placed but does not meet the criteria for negative pressure wound therapy coding 
guidelines, including wound assessment, instructions for ongoing care and total wound surface area less than or 
equal to 50 square centimeters. 
 
The Plan follows Medicare rules. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for negative pressure wound therapy, utilizing 
durable medical equipment, including topical application(s), wound assessment, and instruction(s) for ongoing 
care, per session; total wound(s) surface area less than or equal to 50 square centimeters. Our reviewer says that 
negative pressure wound therapy, utilizing durable medical equipment, including topical application(s), wound 
assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 
square centimeters was not medically necessary. Our physician reviewer found that the application of the 
wound vacuum to this enrollees partial fifth ray amputation site was not medically reasonable or necessary at 
that time. It is well established that the enrollee underwent a partial amputation fifth ray right side. Immediately 
after the surgical procedure was completed, a wound vacuum was applied to the surgical area. Coverage rules 
advise that negative pressure wound therapy, utilizing either durable or disposable medical equipment, involves 
the application of controlled or intermittent negative pressure to a properly dressed wound cavity. Suction is 
applied under airtight wound dressings to promote the healing of open wounds resistant to prior treatments. The 
key element to this coverage rule is wounds resistant to prior treatments.  The medical documentation does not 
support that this open wound was treated with dressing changes prior to application of the wound vacuum. 
There is no evidence of wound measurement or wound depth. Nor is there evidence that this wound was treated 
with standard wound debridement and dressings prior to application of the wound VAC. Therefore, it is my 
opinion that the requested wound VAC was not medically reasonable or necessary for this enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of negative pressure wound therapy, utilizing durable medical equipment, 
including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total 
wound(s) surface area less than or equal to 50 square centimeters have not been met. Therefore, we decided 
that the Plan does not have to pay for negative pressure wound therapy, utilizing durable medical equipment, 
including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total 
wound(s) surface area less than or equal to 50 square centimeters provided on May 7, 2022.