Form Cms-847 - Certificate Of Medical Necessity - Osteogenesis Stimulators - Dme 04.04c
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1
2DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0679
DME 04.04C
CERTIFICATE OF MEDICAL NECESSITY
CMS-847 — OSTEOGENESIS STIMULATORS
SECTION A: Certification Type/Date: INITIAL ___/___/___
REVISE
D ___/___/___ RECERTIFICATION___/___/___
PATIENT NAME, ADDRESS, TELEPHONE and HICN
SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or NPI #
(__ __ __) __ __ __ – __ __ __ __ HICN ______________________
(__ __ __) __ __ __ –__ __ __ __ NSC or NPI #____________
PLACE OF SERVICE ______________ Supply Item/Service/Procedure Code(s): PT DOB ____/____/____ Sex ____ (M/F) Ht. ____(in) Wt ____
NAME and ADDRESS of FACILITY
PHYSICIAN NAME, ADDRESS, TELEPHONE and UPIN or NPI #
if applicable (see reverse)
(__ __ __) __ __ __ – __ __ __ __ 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: ______ ______ ______ ______
ANSWERS
QUESTIONS 1–5 ARE BLANK.
ANSWER QUESTIONS 6–8 FOR NONSPINAL ELECTRICAL OSTEOGENESIS STIMULATOR.
ANSWER QUESTIONS 9–11 FOR SPINAL ELECTRICAL OSTEOGENESIS STIMULATOR.
ANSWER QUESTIONS 6 AND 12 FOR ULTRASONIC OSTEOGENSIS STIMULATOR.
(Check Y for Yes, N for No, or D for Does Not Apply. For questions about months, enter 1–99 or D. If less than one month, enter 1.)
a) oY o N oD
6. In a fracture, has there been no clinically significant radiographic evidence of healing for a minimum of 90 days?
a) oY o N oD
7. (a) Does the patient have a failed fusion of a joint other than the spine?
(b
) How many months prior to ordering the device did the patient have the fusion?
b )____________
_
o
Y
o
N
o
D
8. Does the patient have a congenital pseudoarthrosis?
a)
o
Y
o
N
o
D
9. (a) Is the device being ordered as a treatment of a failed single level spinal fusion surgery in a patient who has
not had a recent repeat fusion?
b)
(b) How many months prior to ordering the device did the patient have the fusion?
a) o Y o N o
D
10. (a) Is the device being ordered as an adjunct to repeat single level spinal fusion surgery in a patient with a
previously failed spinal fusion at the same level(s)?
b)_____________
(b) How many months prior to ordering the device did the patient have the repeat fusion?
c)______________
(c) How many months prior to ordering the device did the patient have the previously failed fusion?
o Y o N o D
11. Is the device being ordered following multi¬level spinal fusion surgery?
ure?
o Y o N o D
12. Has there been at least one open surgical intervention for treatment of the fract
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 Iall items, accessories and option ordered; (2) Suppliers 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 _____/_____/_____
Signature and Date Stamps Are Not Acceptable.
Form CMS–847 (03/14)
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