DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. OMB 0938-0679
CERTIFICATE OF MEDICAL NECESSITY
CMS-10269: POSITIVE AIRWAY PRESSURE (PAP) DEVICES FOR OBSTRUCTIVE SLEEP APNEA
Certification Type/Date: INITIAL
PATIENT NAME, ADDRESS, TELEPHONE and HICN
SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or NPI #
(__ __ __) __ __ __ - __ __ __ __
(__ __ __) __ __ __ - __ __ __ __
NSC or NPI # ____________________________
PLACE OF SERVICE __________________________
PT DOB ____/____/____; Sex ____ (M/F) ; HT.______(in.) ; WT._____(lbs.)
NAME and ADDRESS of FACILITY if applicable
PHYSICIAN NAME, ADDRESS (Printed or Typed)
PHYSICIAN’S NSC or NPI #: ____________________________________________
PHYSICIAN’S TELEPHONE #: (__ __ __) __ __ __- __ __ __ __
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): ___________ ___________ ___________ ___________
ANSWER QUESTIONS 1–7 FOR INITIAL EVALUATION
ANSWER QUESTIONS 8–10 FOR FOLLOW-UP EVALUATION (RECERTIFICATION)
(Check Y for Yes, N for No, D for Does Not Apply)
Is the device being ordered for the treatment of obstructive sleep apnea (ICD-9 diagnosis code 327.23)?
If YES, continue to Questions 2–5; If NO, Proceed to Section D
Enter date of initial face-to-face evaluation
Enter date of sleep test (If test spans multiple days, enter date of first day of test)
Was the patient’s sleep test conducted in a facility-based lab?
What is the patient’s Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI)?
Does the patient have documented evidence of at least one of the following? Excessive daytime sleepiness,
impaired cognition, mood disorders, insomnia, hypertension, ischemic heart disease or history of stroke.
If a bilevel device is ordered, has a CPAP device been tried and found ineffective?
Enter date of follow-up face-to-face evaluation.
Is there a report documenting that the patient used PAP ≥ 4 hours per night on at least 70% of nights in a
30 consecutive day period?
10. Did the patient demonstrate improvement in symptoms of obstructive sleep apnea with the use of PAP?
NAME OF PERSON ANSWERING SECTION B QUESTIONS, IF OTHER THAN PHYSICIAN (Please Print):
NAME: ____________________________________________ TITLE: ____________________________ EMPLOYER: __________________________________
SECTION C: Narrative Description of Equipment and Cost
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 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-10269 (12/09)