Certificate Of Medical Necessity Cms-849 - Seat Lift Mechanisms
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1
2DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0679
CERTIFICATE OF MEDICAL NECESSITY
DME 07.03A
CMS-849 — SEAT LIFT MECHANISMS
SECTION A: Certification Type/Date: INITIAL ___/___/___ REVISED ___/___/___ RECERTIFICATION___/___/___
PATIENT NAME, ADDRESS, TELEPHONE and HICN
SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or NPI #
(__ __ __) __ __ __ - __ __ __ __ HICN _______________________
(__ __ __) __ __ __ - __ __ __ __ NSC or NPI #_________________
PLACE OF SERVICE ______________ Supply Item/Service Procedure Code(s): PT DOB ____/____/____ Sex ____ (M/F) Ht. ____(in) Wt ____
__________
NAME and ADDRESS of FACILITY
PHYSICIAN NAME, ADDRESS, TELEPHONE and UPIN or NPI #
if applicable (see reverse)
__________
__________
__________
(__ __ __) __ __ __ - __ __ __ __ UPIN or NPI #_________________
SECTION B: Information in this Section May Not Be Completed by the Supplier of the Items/Supplies.
EST. LENGTH OF NEED (# OF MONTHS): ______ 1-99 (99=LIFETIME)
DIAGNOSIS CODES: ______ ______ ______ ______
ANSWERS
ANSWER QUESTIONS 1-5 FOR SEAT LIFT MECHANISM
(Check Y for Yes, N for No, or D for Does Not Apply)
o Y
o N
o D
1.
Does the patient have severe arthritis of the hip or knee?
2.
Does the patient have a severe neuromuscular disease?
o Y
o N
o D
3.
Is the patient completely incapable of standing up from a regular armchair or any chair in his/her home?
o Y
o N
o D
o Y
o N
o D
4.
Once standing, does the patient have the ability to ambulate?
5.
Have all appropriate therapeutic modalities to enable the patient to transfer from a chair to a standing position
o Y
o N
o D
(e.g., medication, physical therapy) been tried and failed? If YES, this is documented in the patient’s medical
records.
NAME OF PERSON ANSWERING SECTION B QUESTIONS, IF OTHER THAN PHYSICIAN (Please Print):
NAME: ____________________________________________ TITLE: ____________________________ EMPLOYER:_________________________________
SECTION C: Narrative Description of Equipment and Cost
(1) Narrative description of all items, accessories and options ordered; (2) Supplier’s charge; and (3) Medicare Fee Schedule Allowance for
each item, accessory, and option. (see instructions on back)
SECTION D: PHYSICIAN Attestation and Signature/Date
I certify that I am the treating physician identified in Section A of this form. I have received Sections A, B and C of the Certificate of
Medical Necessity (including charges for items ordered). Any statement on my letterhead attached hereto, has been reviewed and signed
by me. I certify that the medical necessity information in Section B is true, accurate and complete, to the best of my knowledge, and I
understand that any falsification, omission, or concealment of material fact in that section may subject me to civil or criminal liability.
PHYSICIAN’S SIGNATURE_________________________________________________________________________ DATE _____/_____/_____
Signature and Date Stamps Are Not Acceptable.
Form CMS-849 (11/11)
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