Form Cms-846 Certificate Of Medical Necessity Cms-846 - Pneumatic Compression Devices

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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)

1. Does the patient have chronic venous insufficiency with venous stasis ulcers?

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?

3. Has the patient had radical cancer surgery or radiation for cancer that interrupted normal lymphatic drainage of

the extremity?

4. Does the patient have a malignant tumor with obstruction of the lymphatic drainage of an extremity?

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)