Integrated Certificate Of Medical Necessity - Cpap/bipap Rx
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12000 Bloomingdale Road, Ste 205 Glendale Heights, IL 60139 (630) 582.0
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Fax: (630) 582.3787
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Certificate of Medical Necessity – CPAP/BIPAP Rx
PATIENT INFORMATION
Patient Name
Date of Birth
Social Security #
Emergency Contact/Phone #
Address
City/State/Zip Code
Home Phone #
Alternate Phone #
INSURANCE INFORMATION
Name of Insurance Company
Insurance Company Phone #
Insured Name
Insured Date of Birth
Group #
I.D. #
Please Check Box of Equipment Needed
* Duration of Equipment: LIFETIME –OR- _____________________
Diagnosis:
327.21
327.23
780.53
Obstructive Sleep Apnea
Other: ____________________
CPAP (E0601) (attach current sleep study) Setting @ _________ CWP with mask (A7034), tubing (A7037), and headgear
(A7035)
C-Flex with a comfort setting @ 2 or: ___________
Machine or Mask Special Preference: ______________________________________________________________
Auto PAP (E0601) (attach current sleep study) Setting @ __________ to _________ CWP with mask (A7034), tubing
(A7037), and headgear (A7035)
Machine or Mask Special Preference: ___________________________
BIPAP (E0470)
BIPAP ST (E0471) (attach current sleep study) mask (A7034), tubing (A7037), and headgear (A7035)
Settings @ ___________ IPAP and _____________ EPAP if ST B/R: _____________
Machine or Mask Special Preference: ______________________________________________________________
Humidifier
Heated (E0562)
Cool (E5061)
Download:
1& 6 Months or _________________
The above patient has been diagnosed by polysomnography with Obstructive Sleep Apnea (OSA), a condition in the muscle that controls the tongue
and soft palate to relax too much during sleep and obstruct the upper airway, preventing breathing. Management of OSA involves the use of a
Continuous Positive Airway Pressure (CPAP) or BI-LEVEL Device. CPAP/BIPAP therapy is considered the best available and most cost effective
therapy for OSA. It provides an alternative to tracheotomy, or to the less radical uvulopalatopharynogoplasty surgery, for this patient whose disease
if left untreated is potentially life threatening.
Oxygen @ _____________________ LPM Nocturnal via CPAP/BIPAP
Concentrator (E1390)
Other:__________________________________________________________________________________________
Physician:
Lic#
UPIN #
Address:
Phone:
Fax:
Contact Name:
Physician Signature:
Date:
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Parent category: Medical