DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0679
CERTIFICATE OF MEDICAL NECESSITY
DME MAC 04.04B
CMS-846 — PNEUMATIC COMPRESSION DEVICES
SECTION A
Certification Type/Date: INITIAL ___/___/___
REVISED ___/___/___
RECERTIFICATION___/___/___
PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER
SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or applicable
NPI NUMBER/LEGACY NUMBER
Borbas Pharmacy
2046 Bath Avenue
Brooklyn, NY 11214
7186779066
1801926019
(__ __ __) __ __ __ - __ __ __ __ HICN _______________________
(__ __ __) __ __ __ - __ __ __ __ NSC or NPI #_________________
PLACE OF SERVICE______________
HCPCS CODE
PT DOB ____/____/____ Sex ____ (M/F) Ht. ____(in) Wt ____(lbs.)
__________
NAME and ADDRESS of FACILITY
PHYSICIAN NAME, ADDRESS, TELEPHONE and applicable
if applicable (see reverse)
NPI NUMBER or UPIN
__________
__________
__________
(__ __ __) __ __ __ - __ __ __ __ 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 (ICD-9): ______ ______ ______ ______
ANSWERS
ANSWER QUESTIONS 1–5 FOR PNEUMATIC COMPRESSION DEVICES
(Circle Y for Yes, N for No, Unless Otherwise Noted)
Y
N
1. Does the patient have chronic venous insufficiency with venous stasis ulcers?
Y
N
2. If the patient has venous stasis ulcers, have you seen the patient regularly over the past six months and treated
the ulcers with a compression bandage system or compression garment?
Y
N
3. Has the patient had radical cancer surgery or radiation for cancer that interrupted normal lymphatic drainage of
the extremity?
Y
N
4. Does the patient have a malignant tumor with obstruction of the lymphatic drainage of an extremity?
Y
N
5. Has the patient had lymphedema since childhood or adolescence?
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 _____/_____/_____
Form CMS-846 (09/05)