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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 are covered for wounds in the home setting when 
the beneficiary has a chronic Stage III or IV 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 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 
 
You can find this rule in Local Coverage Determination (LCD): Negative Pressure Wound Therapy Pumps 
(L33821) - Effective January 1, 2020. 
 
The rules say that in order for coverage to continue for NWPT, a licensed medical professional must do the 
following: 
 
1. On a regular basis, 
 
a. Directly assess the wound(s) being treated with the pump, and 
b. 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 January 1, 2020. 
 
The rules say that coverage for NWPT will end and be denied as not reasonable and necessary with any of the 
following, whichever occurs earliest: 
 
1. A licensed medical professional ceases directly assessing the wounds or supervising/directly performing the 
dressing changes, and on at least a monthly basis, the changes in the ulcer are not documented 
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 an 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 January 1, 2020. 
 
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.