Form Cms-10269 - Certificate Of Medical Necessity - Dme 03.03 - Positive Airway Pressure (Pap) Devices For Obstructive Sleep Apnea

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Form Approved

CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB No. OMB 0938-0679

CERTIFICATE OF MEDICAL NECESSITY

DME 03.03

CMS-10269: POSITIVE AIRWAY PRESSURE (PAP) DEVICES FOR OBSTRUCTIVE SLEEP APNEA

SECTION A:

Certification Type/Date: INITIAL

RECERTIFICATION

____

PATIENT NAME, ADDRESS, TELEPHONE and HICN

SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or NPI #

(__ __ __) __ __ __ - __ __ __ __

HICN _________________________

(__ __ __) __ __ __ - __ __ __ __

NSC or NPI # ____________________________

PLACE OF SERVICE __________________________

HCPCS CODE

PT DOB ____/____/____; Sex ____ (M/F) ; HT.______(in.) ; WT._____(lbs.)

NAME and ADDRESS of FACILITY if applicable

________________

PHYSICIAN NAME, ADDRESS (Printed or Typed)

(See Reverse)

________________

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): ___________ ___________ ___________ ___________

ANSWERS

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

(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 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)