Medicare AdvantageCoverageHigh impact
Negative Pressure Wound Therapy - Medicare Advantage (Revised)
Humana·Wound Care, General Surgery, Vascular Surgery +3 more·Medicare Advantage
Effective date
Aug 3, 2026
We identified it
Aug 4, 2026
Summary
This is a revised Medicare Advantage policy for Negative Pressure Wound Therapy (NPWT) effective August 3, 2026. The policy clarifies coverage determination based on CMS Local Coverage Determinations (LCDs) that vary by MAC jurisdiction, with Humana using LCD L35125 (Wound Care) criteria for medical necessity determination on NPWT services (CPT 97605-97608). Billing teams must ensure claims comply with jurisdiction-specific LCD requirements and document medical necessity per the specified wound care criteria.
Action Required
By August 3, 2026: Billing team must update claim submission protocols to verify patient's MAC jurisdiction and apply the correct LCD requirement. For most jurisdictions using L35125 (Wound Care LCD), ensure all NPWT claims (CPT 97605, 97606, 97607, 97608) include documentation of medical necessity meeting the referenced LCD criteria before submission. Verify durable medical equipment codes (A6550, E2402) and disposable equipment codes (A7000, K0743) align with the specific MAC's LCD guidance. Update billing system to flag NPWT claims for jurisdictions J6/JK, J15, JJ/JM (which lack application-specific criteria) for manual review. Providers must document wound assessment and medical necessity on all NPWT encounter forms. Failure to comply with jurisdiction-specific LCD requirements will result in claim denials and possible recoupment.