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NF PETI Medical Necessity Certification Form

Eyeglasses (Corrective Lenses) Purchase or Repair Criteria

Client name___________________________________________

Medicaid State ID Number _______________

Medical Necessity (Shall be completed by the attending physician)

Circle all appropriate items.

1. Client demonstrates behavior indicative of visual changes or inadequate correction (e.g.,

stumbling, difficulty finding food on plate, unable to read or see TV, complaints of blurred or

unclear vision).

2. Client has history of visual problems with or without correction, and problem affects

activities of daily living.

3. Other considerations (circle as applicable):

A. Client has the following specific existing visual problems: _________________________

B. Client’s corrective lenses have been broken or lost due to no fault of the nursing facility.

C. Client’s glasses require repair.

D. Client owes a balance from a refraction not covered by Medicare/Medicaid or other insurance.

4. Client requests and has the physical and cognitive ability to wear and benefit from corrective

lenses.

Facility Instructions

1. The evaluation for corrective lenses (eyeglasses) must be part of a comprehensive general

ocular examination conducted by a licensed ophthalmologist or optometrist.

2. Medicare and/or Medicaid shall be billed for any covered services and denied before

submittal to the NF PETI program for review.

3. The medical necessity for prescribed corrective lenses shall be based on a comprehensive

ocular evaluation/examination and not solely based on the client’s refractive status.

4. Purchase of new corrective lenses to replace existing corrective lenses shall include

documentation of the reason for replacement.

5. Attach a copy of the itemized statement or treatment plan which includes the procedure code,

the diagnosis code and the costs for each item.

Requested NF PETI amount: ______________

I certify that I consider the supplies and or services included in this request to be medically

necessary and that there are no medical or cognitive contraindications to the provision of the

supply/service.

Signature of Attending Physician_____________________________Date______License #____

Signature of Opthalmologist_________________________________Date______License#_____

Signature of Optometrist____________________________________Date______License#_____

I agree to the purchase of the supplies and/or equipment covered by this request. I understand

that NF PETI may not cover the entire cost.

Signature of Client/Responsible Party_______________________________Relationship______

Incomplete forms will be returned for completion.

Revised August 2005

Nf Peti Medical Necessity Certification Form - Eyeglasses (Corrective Lenses) Purchase Or Repair Criteria