Form Cms-846 - Certificate Of Medical Necessity - Pneumatic Compression Devices Dme 04.04b
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1
2DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0679
CERTIFICATE OF MEDICAL NECESSITY
DME 04.04B
CMS-846 — PNEUMATIC COMPRESSION DEVICES
SECTION A: Certification Type/Date: INITIAL ___/___/___ REVISED ___/___/___ RECERTIFICATION___/___/___
PATIENT NAME, ADDRESS, TELEPHONE and HICN
SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or NPI #
(__ __ __) __ __ __ - __ __ __ __ NSC or NPI #_________________
(__ __ __) __ __ __ - __ __ __ __ HICN _______________________
PLACE OF SERVICE ______________ Supply Item/Service Procedure Code(s): PT DOB ____/____/____ Sex ____ (M/F) Ht. ____(in) Wt ____(lbss
__________
PHYSICIAN NAME, ADDRESS, TELEPHONE and UPIN or NPI #
NAME and ADDRESS of FACILITY
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 CODE(S): ______ ______ ______ ______
ANSWERS
ANSWER QUESTIONS 1–5 FOR PNEUMATIC COMPRESSION DEVICES
(Check Y for Yes, N for No, Unless Otherwise Noted)
o Y
o N
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
o Y
o N
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
o Y
o N
of the extremity?
o Y
o N
4.
Does the patient have a malignant tumor with obstruction of the lymphatic drainage of an extremity?
o Y
o 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 _____/_____/_____
Signature and Date Stamps Are Not Acceptable.
Form CMS-846 (11/11)
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