VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
CERTIFICATE OF MEDICAL NECESSITY
DURABLE MEDICAL EQUIPMENT AND SUPPLIES
Note: The CMN can now be used
in place of DMAS-115. The
original requirements for justification
still apply. Additional questions
have been added to the CMN.
Answer all questions that are applicable to DME service being requested.
If answer is yes, you must describe/attach additional information.
(Additional space on reverse)
have impaired mobility?
have impaired endurance?
have restricted activity?
have skin breakdown? (Describe site, size,
depth and drainage)
have impaired respiration? (Identify most
recent PO 2 ________/Saturation level _______
for patients on oxygen)
require assistance with ADL's?
have impaired speech?
8. a) require nutritional supplements? (If yes,
answer b and c below.)
b) sole source or primary source (circle one)
c) height _________ weight _____________
IS THE ITEM SUITABLE FOR USE IN HOME, & DOES THE INDIVIDUAL/CAREGIVER DEMONSTRATE WILLINGNESS/ABILITY TO USE THE EQUIPMENT? YES
Date individual last examined by physician
Date of Onset
Less than 6 months
Greater than 6 months
ADDITIONAL SPACE ON REVERSE
Frequency of Use*
Calories Per Day
PHYSICIAN CERTIFICATION (
MUST BE SIGNED AND DATED BY
I CERTIFY THAT THE ORDERED DME AND SUPPLIES ARE PART OF MY TREATMENT PLAN AND, IN MY OPINION, ARE MEDICALLY NECESSARY.
ORDERING PHYSICIAN'S NAME (print)
*Required fields. If any of these fields are blank the CMN is not valid. The other sections of the CMN can be documented on the CMN or in supporting documentation.
Physician’s signature does not guarantee payment unless all documentation requirements are met. Issuance of a PA does not guarantee payment. Payment is contingent upon
all appropriate documentation being readily available for review. ***Complete diet order must be indicated in Section III
DMAS-352, Revised 8/2015