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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 Negative Pressure Wound Therapy (NPWT) is defined as the application of sub-atmospheric pressure to a wound to remove exudate and debris from wounds. NPWT is delivered through an integrated system of a suction pump, separate exudate collection chamber and dressing sets to a qualified wound. In these systems, exudate is completely removed from the wound site to the collection chamber. Refer to the coding guidelines section of the Policy Article for information about equipment and supply specifications. Other suction pump systems (K0743, K0744, K0745, and K0746) may also be used to remove exudate from a wound. Refer to the Suction Pumps Local Coverage Determination for information about coverage of these items. 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 3 or 4 pressure ulcer, 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
B. 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 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. NPWT pumps (E2402) must be capable of accommodating more than one wound dressing set for multiple wounds on a beneficiary. Therefore, more than one E2402 billed per beneficiary for the same time period will be denied as not reasonable and necessary.
You can find these rules in 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.