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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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules state that this Local Coverage Determination (LCD) offers coverage indications and guidelines for 
wound care involving debridement, electrical stimulation and electromagnetic therapy, negative pressure 
wound therapy, low frequency non-contact non-thermal ultrasound (MIST Therapy), and topical oxygen 
therapy (TOT). For the purposes of this LCD, wound care is defined as care of wounds that are refractory to 
healing or have complicated healing cycles either because of the nature of the wound itself or because of 
complicating metabolic and/or physiological factors. Active wound care procedures are performed to remove 
necrotic tissue and/or devitalized tissue to promote healing. Providers are responsible to determine medical 
necessity and use the appropriate current CPT/HCPCS code for service provided. Please consult the current 
AMA CPT book for the complete code description of the procedures being performed to submit claims. 
This LCD supplements but does not replace, modify, or supersede existing Medicare applicable National 
Coverage Determinations (NCDs) or payment policy rules and regulations for additional wound care. Federal 
statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. 
They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify, or 
supersede applicable state statutes regarding medical practice or other health practice professions acts, 
definitions and/or scopes of practice. All providers who report services for Medicare payment must fully 
understand and follow all existing laws, regulations, and rules for Medicare payment for additional wound care 
sessions and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual 
instructions and policies are provided in CMS National Coverage Policy section. This policy does not address 
metabolically active human skin equivalent/substitute dressings, burns, skin cancer or hyperbaric oxygen 
therapy. You can find this rule at the Medicare Local Coverage Determination (LCD)- L37228, Wound Care. 
 
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.