Appeal type: unknown
Decision: unknown

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 CFR 422.101.The rules say 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.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, andb. Application of dressings to maintain a moist wound environment, andc. Debridement of necrotic tissue if present, andd. Evaluation of and provision for adequate nutritional status5. For Stage III or IV pressure ulcers:a. The beneficiary has been appropriately turned and positioned, andb. 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), andc. The beneficiary's moisture and incontinence have been appropriately managed 4. For neuropathic (for example, diabetic) ulcers:a. The beneficiary has been on a comprehensive diabetic management program, andb. Reduction in pressure on a foot ulcer has been accomplished with appropriate modalities 3. For venous insufficiency ulcers:a. Compression bandages and/or garments have been consistently applied, andb. Leg elevation and ambulation have been encouragedB. Ulcers and Wounds Encountered in an Inpatient Setting: 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 physician, 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).CONTINUED COVERAGE:C. For wounds and ulcers described under A or B above, once placed on an NPWT pump and supplies, in order for coverage to continue, a licensed medical professional must do the following:1. On a regular basis,a. Directly assess the wound(s) being treated with the NPWT pump, andb. Supervise or directly perform the NPWT dressing changes, and 3. On at least a monthly basis, document changes in the ulcer's dimensions and characteristics.If criteria C-1 and C-2 are not fulfilled, continued coverage of the NPWT pump and supplies will be denied asnot reasonable and necessary.WHEN COVERAGE ENDS:D. For wounds and ulcers described under A or B above, an NPWT pump and supplies will be denied as not reasonable and necessary with any of the following, whichever occurs earliest:1. Criteria C1-C2 cease to occur,2. In the judgment of the treating physician, adequate wound healing has occurred to the degree that NPWT may be discontinued,3. Any measurable degree of wound healing has failed to occur overthe prior month. Wound healing is defined as improvement occurring in either surface area (length times width) or depth of the wound4. 4 months (including the time NPWT was applied in an inpatient setting prior to discharge to the home) have elapsed using an NPWT pump in the treatment of the most recent wound5. Once equipment or supplies are no longer being used for the beneficiary, whether or not by the physician's orderWhen NPWT therapy exceeds 4 months on the most recent wound and reimbursement ends, individual consideration for one additional month at a time may be sought using the appeals process. Information from the treating physician's medical record, contemporaneous with each requested one-month treatment time period extension, must be submitted with each appeal explaining the special circumstances necessitating the extended month of therapy. Note, the LCD provides coverage for the use of NPWT limited to initiating healing of the problem wounds described in the "Coverage Indications, Limitations and/or Medical Necessity" section of the related LCD rather than continuation of therapy to complete healing since there is no published medical iterature demonstrating evidence of a clinical benefit for the use of NPWT to complete wound healing. Therefore, general, vague or nonspecific statements in the medical record such as "doing well, want to continue until healed" provide insufficient information to justify the need for extension of treatment. The medical record must provide specificand detailed information to explain the continuing problems with the wound, what additional measures are being undertaken to address those problems and promote healing and why a switch to alternative treatments alone is not possible.You can find this information in Medicare's Local Coverage Article: Negative Pressure Wound Therapy Pumps -Policy Article (A52511) and Local Coverage Determination (LCD): Negative Pressure Wound Therapy Pumps (L33821).If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.