For all ulcers or wounds, the wound therapy program must include a minimum of all the following general measures, which should either be addressed, applied, or considered and ruled out prior to application of NPWT. Please submit the following documentation to support medical necessity:
I prescribe negative pressure therapy pump (NPWT) E2402 as medically necessary and certify
that all other treatment modalities have been utilized and evaluated. I certify that I am the
treating physician identified in Section E of this form.
I hereby understand the principles
of NPWT and the product information regarding the Smith & Nephew NPWT.