DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0679
CERTIFICATE OF MEDICAL NECESSITY
DME MAC 04.04B
CMS-846 — PNEUMATIC COMPRESSION DEVICES
Certification Type/Date: INITIAL ___/___/___
PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER
SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or applicable
NPI NUMBER/LEGACY NUMBER
2046 Bath Avenue
Brooklyn, NY 11214
(__ __ __) __ __ __ - __ __ __ __ HICN _______________________
(__ __ __) __ __ __ - __ __ __ __ NSC or NPI #_________________
PLACE OF SERVICE______________
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 #_________________
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): ______ ______ ______ ______
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
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:__________________________
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)
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)