CERTIFICATE OF MEDICAL NECESSITY CMS-484227 OXYGEN SECTION A: Certi037cation Type/Date: INITIAL // REVISED // RECERTIFICATIO SUPPLIER NAME, ADDRESS, TELEPHONE an ( ) 226 NSC or NPI PLACE OF SERVICE S upply Item/Service Procedure Code(s): PT DOB // Sex035035(M/F)035Ht.035(in NAME035and035ADDRESS035of035FACILITY035if035applicable035(see035reverse)035 PHYSICIAN035NAME,035ADDRESS,035TELEPHONE035an035 (035035)035035035035226035035035035035UPIN035or035NPI035 SECTION B: Information in this Section May Not Be Completed by the Supplier of the It a)mm035Hg035b)%035c)// Enter the result of recent test taken on or before the certi037cation date listed inSection A. Enter (a)arterial blood gas PO2 and/or (b) oxygen saturation test;date of test. 120350353 2.Was the test in Question 1 performed (1) with the patient in a chronic stable state as an outpatient, (2)within two days prior to discharge from an inpatient facility to home, or (3)under other circumstances? 103503520350353 3.Check the one number for the condition of the test in Question 1: (1) At Rest; (2) During Exercise;(3)During Sleep Y035035N035035D 4.If035you035are035ordering035portable035oxygen,035is035the035patient035mobile035within035the035home?035If035you035are035not035ordering portable035oxygen,035check035D. LPM035 5.Enter035the035highest035oxygen035036ow035rate035ordered035for035this035patient035in035liters035per035minute.035If035less035than0351035LPM, enter035an035223X224. a)mm035Hg035b)%035c)// If greater than 4 LPM is prescribed, enter results of recent test taken on 4 LPM. This may be anarterial blood gas PO2 and/or (b) oxygen saturation test with patient in a chronic stable state.Enter date of test (c). Y N 7.Does the patient have dependent edema due to congestive heart failure?Y N 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. (1)Narrative description of all items, accessories and option ordered; (2) Suppliers charge; and (3) Medicare Fee Schedule Allowance foreach item, accessory, and option (see instructions on back) DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES EST.035LENGTH035OF035NEED035(#035OF035MONTHS):035035122699035(99=LIFETIME)035035 035 DME 484 DIAGNOSIS035CODES:035035035035035 ANSWERS035 ANSWER035QUESTIONS03512269.035(Check035Y035for035Yes,035N035for035No,035or035D035for035Does035Not035Apply,035unless035otherwise035noted.)035 ANSWER035QUESTIONS03579035ONLY035IF035PO2035=0355622659035OR035OXYGEN035SATURATION035=03589035IN035QUESTION0351035 Y N 9.Does the patient have a hematocrit greater than 56%? NAME OF PERSON ANSWERING SECTION B QUESTIONS, IF OTHER THAN PHYSICIAN (Please Print): NAME TITLEEMPLOYER SECTION C: Narrative Description of Equipment and Cost SECTION D: PHYSICIAN Attestation and Signature/Date I certify that I am the treating physician identi037ed in Section A of this form. I have received Sections A, B and C of the Certi037cate 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 falsi037cation, omission, or concealment of material fact in that section may subject me to civil or criminal liability. PHYSICIAN222S SIGNATUREDATE //Signature and Date Stamps Are Not Acceptable.Form CMS226484 () American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETING THE CERTIFICATE OF MEDICAL NECESSITY FOR OXYGEN SECTION A: CERTIFICATION035 DATE:035 PATIENT035 INFORMATION:035 SUPPLIER035 INFORMATION:035 PLACE035OF035SERVICE:FACILITY035NAME:035035SUPPLY035ITEM/SERVICE035PROCEDURE035CODE(S):035PATIENT035DOB,035HEIGHT,035WEIGHT035AND035SEX:035PHYSICIAN035NAME,035ADDRESS:035PHYSICIAN035INFORMATION:035PHYSICIAN222S035TELEPHONE035NO:035SECTION B: EST.035LENGTH035OF035NEED:035035DIAGNOSIS035CODES:035035QUESTION035SECTION:035035NAME035OF035PERSON035ANSWERING035SECTION035B035QUESTIONS:035SECTION C: NARRATIVE035DESCRIPTION035OF035EQUIPMENT035&035COST:035SECTION D: PHYSICIAN035ATTESTATION:035PHYSICIAN035SIGNATURE035AND035DATE:035 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0679. The time required to complete this information collection is estimated to average 12 minutes per response, including the time to review instructions, search existing resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Blvd. Baltimore, Maryland 21244. DO NOT SUBMIT CLAIMS TO THIS ADDRESS. Please see http://www.medicare.gov/ for information on claim filing. Form035CMS-484035()035INSTRUCTIONS035 American LegalNet, Inc. www.FormsWorkFlow.com