Form 02900 Colorado Department Of Health Care Policy And Financing

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Ohio Department of Medicaid

CERTIFICATE OF MEDICAL NECESSITY/PRESCRIPTION

APNEA MONITORS

Instructions: The Certificate of Medical Necessity (CMN) must be used for apnea monitors under the Ohio Medicaid Program. This form must be completed and carry the proper

signature, where indicated, before requests will be considered for prior authorization.

Name of Consumer

Medicaid Number

__ __ __ __ __ __ __ __ __ __ __ __

Street Address

City/State/Zip

Date of Birth

List other respiratory equipment in use

Prior Dates of Service

Section A - Must be completed by prescriber

Diagnosis(es) Include ICD-9 codes and description

The first 4 months of rental are covered without prior authorization. Check the appropriate clinical indication(s) listed below (check all that

apply to the initial 4 month rental period):

One or more apparent life-threatening events requiring mouth-

Infant with abnormal pneumogram at discharge

to-mouth resuscitation or vigorous stimulation

Infants with severe upper airway abnormalities (e.g.,

Symptomatic preterm infant (active medical management of

achondroplasia, Pierre-robin syndrome, etc.)

apnea of prematurity)

Multiple birth SIDS survivor

Sibling of one or more sudden infant death syndrome (SIDS)

Severe gastroesophageal reflux associated with apnea

victims

Infants with other disorders that demonstrate a need for close

Infant required home oxygen therapy or invasive/non-invasive

cardiorespiratory monitoring to facilitate discharge. Specify:

ventilatory support (technology dependent)

Tracheotomized infant (technology dependent)

Continued monitoring (check all that apply)

Infant is

Technology dependent

Non-technology dependent

Apnea episode:

Date: _____/_____/_____

Length of episode: _________________________

Multiple apnea episodes: Number: ___________

Average length of episodes: _________________

Bradycardia episode:

Date: _____/_____/_____

Heart rate: __________

Length of episode: ___________

Multiple bradycardia episodes:

Average heart rate: ________

Average length of episode: ___________

Recent emergency room visit or

Hospital admission, for ALTE

Date of visit/admission: _____/_____/_____

Technology dependent infant:

Equipment (other than apnea monitor) is still in use.

Infant is still in need of monitoring

Specify other technology/equipment:

SIDS Sibling

Date of Birth

Sibling Date of Death

Section B - Must be completed by the Provider of medical suppler services

Provider adheres to the requirements for use of home monitoring as recommended in the “Supplemental Statement on Home Monitoring - 1984” adopted

by the Committee on Sudden Infant Death Syndrome of the Ohio Chapter of the American Academy of Pediatrics:, in accordance with rule 5101:3-10-09 of

the OAC.

I certify that the information in Section C of this certificate of medical necessity is true. I understand that any falsification, omission, or concealment of

material fact may subject me to civil or criminal liability.

Provider authorized representative (PRINT name)

Provider Authorized Representative Signature

Date

Section C - Prescriber Attestation and Signature/Date

Prescriber’s Name (PRINTED)

I certify that I am the prescriber identified above. I certify that the information I have completed in this certificate is of medical necessity and any

information on any attached documents signed and dated by me is true to the best of my knowledge. I understand that any falsification, omission, or

concealment of material fact may subject me to civil or criminal liability.

Prescriber Signature

Date

Ohio Medicaid Provider #

ODM 02900 (7/2014)

Formerly JFS 02900