MEDICAID CERTIFICATE OF MEDICAL NECESSITY FORM FOR OXYGEN Form

SOUTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
MEDICAID CERTIFICATE OF MEDICAL NECESSITY FORM
FOR OXYGEN

SECTION A: MUST BE COMPLETED BY DME PROVIDER:

(1) Recipient’s name: __ Medicaid # (10 digits): ___

(2) DOB // Sex: HT: __ (in) WT __ Date of service: //___

(3) Provider’s name: __ Provider’s DME #: __ NPI #: __

(4) Street address: __ City: __ State: Zip: ___ Local telephone #: ___

(5) Provider’s signature: __ Date: __

(6) LIST ALL PROCEDURE CODES THAT ARE ORDERED BY THE TREATING/ORDERING PHYSICIAN FOR EQUIPMENT:
_

SECTION B: MUST BE COMPLETED BY TREATING/ORDERING PHYSICIAN:

(7) Diagnosis codes (ICD) _ (Descriptions): ___
_

(8) ANSWERS ANSWER QUESTIONS 1-9. (Circle Y for Yes, N for No, or D for Does Not Apply, unless otherwise noted)

| (a) | __ mm Hg | 1. Enter the result of most recent recent test taken on or before the certification date listed in Section A. Enter (a) arterial blood gas PO2 and/or (b) oxygen saturation test. Enter date of test (c) |

| (b) | / / / % | |

| (c) | | |

| Y N | | 2. Was the test in Question 1 performed EITHER with the patient in a chronic stable state as an outpatient OR within two days prior to discharge from an inpatient facility to home? |

| 1 2 3 | | 3. Circle the one number for the condition of the test in Question 1: (1) At Rest; (2) During Exercise; (3) During Sleep |

| XXXXXXXXXXXX XXXXXXXXXXXX XXXXXXXXXXXX | | 4. Physician/provider performing test in Question 1 (and, if applicable, Question 7) Print/type name and address below NAME: __ ADDRESS: __ |

| Y N D | | 5. If you are ordering portable oxygen, is the patient mobile within the home? If you are not ordering portable oxygen, circle D |

| __ LPM | | 6. Enter the highest oxygen flow rate ordered for this patient in liters per minute. If less than 1 LPM, enter a"X" |

IF PO2 = 56-60 OR OXYGEN SATURATION = < 89%, AT LEAST ONE OF THE FOLLOWING CRITERIA MUST BE MET.

| Y N D | 7. Does the patient have dependent edema due to congestive heart failure? |

| Y N D | 8. Does the patient have cor pulmonale or pulmonary hypertension documented by P pulmonale on an EKG or by an echocardiogram, gated blood pool scan or direct pulmonary artery pressure measurement? |

| Y N D | 9. Does the patient have a hematocrit greater than 56%? |

NAME OF PERSON ANSWERING SECTION C QUESTIONS, IF OTHER THAN PHYSICIAN (Please Print): __
NAME: __ TITLE: __ EMPLOYER: __

(9) Please indicate the date that the patient was seen for the equipment/supplies prescribed: __

(10) Please indicate the Prescription date: __

(11) Duration of need (maximum of 12 months):
(Please indicate by months, not to exceed 12).

I certify that I am the treating/ordering physician identified in Section B of this form. Any statement attached hereto has been reviewed and signed by me. I certify that the medical necessity information is true, accurate and complete, to the best of my knowledge, and I understand that any falsification, omission or concealment of material may subject me to civil or criminal liability. Additionally, I certify that the requested equipment/supplies are appropriate for the patient.

(12) PRINT PHYSICIAN’S NAME __ PHYSICIAN’S NPI # __

PHYSICIAN’S SIGNATURE __ DATE / / ___ (SIGNATURE AND DATE STAMPS ARE NOT ACCEPTABLE)