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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 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: 
 
    Ulcers and Wounds in the Home Setting: 
 
    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. 
 
            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: 
 
                Documentation in the beneficiary's medical record of evaluation, care, and wound measurements by a 
licensed medical professional, and 
                Application of dressings to maintain a moist wound environment, and 
                Debridement of necrotic tissue if present, and                 Evaluation of and provision for adequate nutritional status 
 
            For Stage 3 or 4 pressure ulcers: 
 
                The beneficiary has been appropriately turned and positioned, and 
                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 
                The beneficiarys moisture and incontinence have been appropriately managed 
 
            For neuropathic (for example, diabetic) ulcers: 
 
                The beneficiary has been on a comprehensive diabetic management program, and 
                Reduction in pressure on a foot ulcer has been accomplished with appropriate modalities 
 
            For venous insufficiency ulcers: 
              
                Compression bandages and/or garments have been consistently applied, and 
                Leg elevation and ambulation have been encouraged 
 
    Ulcers and Wounds Encountered in an Inpatient Setting: 
 
            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. 
 
            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. 
 
A licensed health care professional, for the purposes of this policy, may be a physician, physicians assistant 
(PA), registered nurse (RN), licensed practical nurse (LPN), or physical therapist (PT). The treating practitioner 
should be licensed to assess wounds and/or administer wound care within the state where the beneficiary is 
receiving NPWT. 
 
OTHER EXCLUSIONS FROM COVERAGE: 
 
A NPWT pump and supplies will be denied at any time as not reasonable and necessary if one or more of the 
following are present: 
 
    The presence in the wound of necrotic tissue with eschar, if debridement is not attempted;     Osteomyelitis within the vicinity of the wound that is not concurrently being treated with intent to cure; 
    Cancer present in the wound; 
    The presence of an open fistula to an organ or body cavity within the vicinity of the wound. 
 
NPWT systems, pumps and their associated supplies, that have not been specifically designated as being 
qualified to use HCPCS codes E2402 via written instructions from the Pricing, Data Analysis and Coding 
(PDAC) Contractor will be denied as not reasonable and necessary. 
 
CONTINUED COVERAGE: 
 
    For wounds and ulcers described under A or B above, once placed on a NPWT pump and supplies, in order 
for coverage to continue, a licensed medical professional must do the following: 
 
            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 
 
            On at least a monthly basis, document changes in the ulcers dimensions and characteristics. 
 
If criteria C-1 and C-2 are not fulfilled, continued coverage of the NPWT pump and supplies will be denied as 
not reasonable and necessary. 
 
SUPPLIES: 
 
Coverage is provided up to a maximum of 15 dressing kits (A6550) per wound per month. 
 
Coverage is provided up to a maximum of 10 canister sets (A7000) per month unless there is documentation 
evidencing a large volume of drainage (greater than 90 ml of exudate per day). 
 
For high volume exudative wounds, a stationary pump with the largest capacity canister must be used. 
 
When billing for quantities of canisters greater than those described in the policy as the usual maximum 
amounts, there must be clear and explicit information in the medical record that justifies the additional 
quantities. You can find these rules in the 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.