Appeal type: unknown
Decision: unknown

 
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. 
 
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. 
 
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.