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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 say that a Negative Pressure Wound Therapy pump (E2402) and supplies (A6550, A7000) are covered in the home settings if the beneficiary has a chronic Stage 3 or 4 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, 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 3 or 4 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, 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 You can find this rule in Local Coverage Determination (LCD):Negative Pressure Wound Therapy Pumps (L33821) - Effective May 1, 2021. The rules say that for wounds and ulcers described above, once placed on a NPWT pump and supplies, in order for coverage to continue, a licensed medical professional must do the following: 1. On a regular basis, directly assess the wound(s) being treated with the NPWT pump, and supervise or directly perform the NPWT dressing changes, and 2. On at least a monthly basis, document changes in the ulcer's dimensions and characteristics. You can find this rule in Local Coverage Determination (LCD):Negative Pressure Wound Therapy Pumps (L33821) - Effective May 1, 2021. The rules say that for wounds described above, a NPWT pump and supplies will be denied as not reasonable and necessary with any of the following, whichever occurs earliest: 1. The continued coverage criteria above cease to occur. 2. In the judgment of the treating practitioner, adequate wound healing has occurred to the degree that NPWT may be discontinued, 3. Any measurable degree of wound healing has failed to occur over the prior month. Wound healing is defined as improvement occurring in either surface area (length times width) or depth of the wound 4. 4 months (including the time NPWT was applied in an inpatient setting prior to discharge to the home) have elapsed using a NPWT pump in the treatment of the most recent wound 5. Once equipment or supplies are no longer being used for the beneficiary, whether or not by the treating practitioner's order You can find this rule in Local Coverage Determination (LCD):Negative Pressure Wound Therapy Pumps (L33821) - Effective May 1, 2021.
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.