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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules state that a Negative Pressure Wound Therapy pump (E2402) and supplies (A6550, A7000) are
covered when either criterion A or B is met:

A. Ulcers and Wounds in the Home Setting:

The beneficiary has a chronic Stage III or IV pressure ulcer (see Appendices Section), neuropathic (for
example, diabetic) ulcer, venous or arterial insufficiency ulcer, or a chronic (being present for at least
30 days) ulcer of mixed etiology. A complete wound therapy program described by criterion 1 and
criteria 2, 3, or 4, as applicable depending on the type of wound, must have been tried or considered and
ruled out prior to application of NPWT.

A.

1. For all ulcers or wounds, the following components of a wound therapy program must
include a minimum of all of the following general measures, which should either be
addressed, applied, or considered and ruled out prior to application of NPWT:

a. Documentation in the beneficiary's medical record of evaluation, care, and
wound measurements by a licensed medical professional, and
b. Application of dressings to maintain a moist wound environment, and
c. Debridement of necrotic tissue if present, and
d. Evaluation of and provision for adequate nutritional status

2. For Stage III or IV pressure ulcers:

a. The beneficiary has been appropriately turned and positioned, and
b. The beneficiary has used a group 2 or 3 support surface for pressure ulcers on the
posterior trunk or pelvis (see LCD on support surfaces), and
c. The beneficiary's moisture and incontinence have been appropriately managed

3. For neuropathic (for example, diabetic) ulcers:

a. The beneficiary has been on a comprehensive diabetic management program, and
b. Reduction in pressure on a foot ulcer has been accomplished with appropriate
modalities

4. For venous insufficiency ulcers:

a. Compression bandages and/or garments have been consistently applied, and
b. Leg elevation and ambulation have been encouraged

B. Ulcers and Wounds Encountered in an Inpatient Setting:

A.

1. An ulcer or wound (described under A above) is encountered in the inpatient setting and,
after wound treatments described under A-1 through A-4 have been tried or considered
and ruled out, NPWT is initiated because it is considered in the judgment of the treating
practitioner, the best available treatment option.

2. The beneficiary has complications of a surgically created wound (for example,
dehiscence) or a traumatic wound (for example, pre-operative flap or graft) where there
is documentation of the medical necessity for accelerated formation of granulation tissue
which cannot be achieved by other available topical wound treatments (for example,
other conditions of the beneficiary that will not allow for healing times achievable with
other topical wound treatments).

In either situation B-1 or B-2, NPWT will be covered when treatment is ordered to continue beyond discharge
to the home setting.

If criterion A or B above is not met, the NPWT pump and supplies will be denied as not reasonable and
necessary.

You can find this information in the Local Coverage Determination (LCD): Negative Pressure Wound Therapy
Pumps (L33821).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.