Coverage criteria and letter of medical necessity

Codes

Covered wound types: Chronic Stage III or Stage IV pressure ulcer, Chronic arterial ulcer, Chronic diabetic ulcer, Chronic venous stasis ulcer. Anything else is outside coverage for this therapy.

• The wound is chronic and of a covered typeChronic means not healed within 30 days of occurring. Wounds outside the four covered types are not covered for this therapy.
• At least 30 days of standard wound care first, with no measurable healingStandard care means nutrition review, debridement of dead tissue, a clean moist wound bed, treatment of infection, offloading for a diabetic foot ulcer and compression for a venous ulcer.
• Used as an addition to standard care, never instead of itThe therapy is adjunctive. Standard wound care has to carry on unchanged throughout the course.
• Reviewed by the treating clinician at least every 30 daysEach review records wound size, exudate and dead tissue so healing can be judged.
• Measurable healing in each 30-day block, or the course stopsMeasurable healing is a smaller area or volume, less exudate, or less dead tissue. No measurable healing in a 30-day period means continued treatment is not covered.
• Stopped once the wound bed is fully covered with new skinTreatment ends at 100% epithelialisation.

Until every condition is confirmed and documented, expect the request to be refused.

Letter of medical necessity

Five short steps, in the order the letter reads. Anything left empty stays a visible blank in square brackets rather than being invented.

September 18, 2026

[payer name]
Re: [patient name] — date of birth [date of birth], member [member number]

Letter of medical necessity

I am the treating [role] for the patient named above at [practice name]. I am requesting authorisation for Adjunctive electromagnetic therapy for a chronic non-healing ulcer.

Diagnosis: [diagnosis].
Wound site: [site]. First noted [date], and it has not healed since.
Wound area at first assessment: [area] cm². Most recent measured area: [area] cm².

Standard wound care has been in place for more than 30 days and continues unchanged: Debridement, moist wound-bed dressing, infection management, nutritional review, and offloading or compression appropriate to the wound type.. Despite this, the wound has shown no measurable healing over that period, documented by serial wound measurement and photography at each visit.

The requested therapy is adjunctive to standard wound care and does not replace any part of it. I will re-assess the wound at least every 30 days, record area, exudate and non-viable tissue at each review, discontinue if no measurable healing is documented in any 30-day period, and discontinue once the wound bed is fully epithelialised.

Serial wound measurements, photographs and session records are attached and available for review on request.

Sincerely,

[clinician name]
[role]
[practice name]

Requested course: 5 sessions per week for 4 weeks, then review

What this page is not

• This is a reference to published policy, not a coverage guarantee or billing advice. Confirm the current rules with the payer before billing.
• Coverage in the United States for wound electromagnetic therapy attaches to the therapy and the wound type, not to any brand.
• This platform's radiofrequency wound protocols are investigational. An investigational protocol is not billable as a cleared treatment.
• Rules elsewhere differ. Outside the United States, follow the local reimbursement scheme.