Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve negative pressure wound therapy electrical pump, 
stationary or portable, wound care set, for negative pressure wound therapy electrical pump, includes all 
supplies and accessories and a canister, disposable, used with suction pump. 
 
You asked the Plan to pre-approve negative pressure wound therapy electrical pump, stationary or portable, 
wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories and 
a canister, disposable, used with suction pump. You say that due to comorbidities, the member will not be able 
to use conservative wound care methods. The Plan denied your request. The Plan says the requested durable 
medical equipment and supplies do not meet the Medicare requirements for approval. 
 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 pre-approve negative pressure wound therapy 
electrical pump, stationary or portable, wound care set, for negative pressure wound therapy electrical pump, 
includes all supplies and accessories and a canister, disposable, used with suction pump. Our reviewer says that 
the requested durable medical equipment and supplies are not considered medically necessary in this case. Our 
physician reviewer found that the enrollee has type 2 diabetes (DM) and has osteomyelitis in a foot wound 
requiring debridement surgery, antibiotics, wound care, and a wound VAC. It was reported that the enrollee 
had an infection after use of the wound VAC and required additional treatment. No improvement of the wound 
was noted with the use of the wound VAC. A new wound was noted on the same foot more recently, but the 
wound VAC was discontinued. This is a request for restarting use of the wound VAC. However, the provided 
recent documentation was not from the past three months and there was no recent clear description of an update 
on the enrollees overall clinical status such as how well the diabetes is controlled, how the circulation to the 
foot is, if the enrollee is using pressure relieving methods for the foot, or the nutritional status of the enrollee to 
determine if using the wound VAC would be reasonable and effective. Therefore, without sufficient recent 
support made, the wound VAC and associated supplies will be considered not medically necessary 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 electrical pump, stationary or portable, wound 
care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories and a 
canister, disposable, used with suction pump have not been met. Therefore, we decided that the Plan does not 
have to pre-approve negative pressure wound therapy electrical pump, stationary or portable, wound care set, 
for negative pressure wound therapy electrical pump, includes all supplies and accessories and a canister, 
disposable, used with suction pump.