CERTIFICATE OF MEDICAL NECESSITY CMS-847 227 OSTEOGENESIS STIMULATORS SECTION A: Certi037cation Type/Date: INITIAL //D // RECERTIFICATION// PATIENT NAME, ADDRESS, TELEPHONE and REVISE SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or NPI # ( ) 226 ( ) 226 NSC or NPI # PLACE OF SERVICE Supply Item/Service/Procedure Code(s): PT DOB // Sex (M/F) Ht. (in)en-US Wt NAME and ADDRESS of FACILITY ( ) 226 UPIN or NPI # PHYSICIAN NAME, ADDRESS, TELEPHONE and UPIN or NPI # if applicable (see reverse) SECTION B: Information in this Section May Not Be Completed by the Supplier of the Items/Supplies. EST. LENGTH OF NEED (# OF MONTHS): 122699 (99=LIFETIME) DIAGNOSIS CODES: ANSWERS QUESTIONS 12265 ARE BLANK. ANSWER QUESTIONS 62268 FOR NONSPINAL ELECTRICAL OSTEOGENESIS STIMULATOR. ANSWER QUESTIONS 922611 FOR SPINAL ELECTRICAL OSTEOGENESIS STIMULATOR. ANSWER QUESTIONS 6 AND 12 FOR ULTRASONIC OSTEOGENSIS STIMULATOR. (Check Y for Yes, N for No, or D for Does Not Apply. For questions about months, enter 122699 or D. If less than one month, enter 1.) a)Y N Da)Y N D (bb )Y N D a) Y N Db) a) Y N b)c)6.In a fracture, has there been no clinically signi037cant radiographic evidence of healing for a minimum of 90 days? 7.(a) Does the patient have a failed fusion of a joint other than the spine? ) How many months prior to ordering the device did the patient have the fusion? 8.Does the patient have a congenital pseudoarthrosis? 9.(a) Is the device being ordered as a treatment of a failed single level spinal fusion surgery in a patient who has not had a recent repeat fusion? (b)How many months prior to ordering the device did the patient have the fusion? D 10.(a) Is the device being ordered as an adjunct to repeat single level spinal fusion surgery in a patient with a previously failed spinal fusion at the same level(s)? (b)How many months prior to ordering the device did the patient have the repeat fusion? � (c)How many months prior to ordering the device did the patient have the previously failed fusion? Y N DY N D11.Is the device being ordered following multi254level spinal fusion surgery? 12.Has there been at least one open surgical intervention for treatment of the fracture? NAME OF PERSON ANSWERING SECTION B QUESTIONS, IF OTHER THAN PHYSICIAN (Please Print): �NAME TITLEEMPLOYER SECTION C: Narrative Description of Equipment and Cost (1)Narrative description of Iall items, accessories and option ordered; (2) Suppliers 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 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 CMS226847 () DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES DME 04.04C American LegalNet, Inc. www.FormsWorkFlow.com SECTION A: � CERTIFICATION � DATE: � PATIENT � INFORMATION: � SUPPLIER � INFORMATION: � PLACE OF SERVICE: � FACILITY NAME: � en-USSUPPLY ITEM/SERVICE � en-USPen-USROCEDURE CODE(S): � PATIENT DOB, HEIGHT, � WEIGHT AND SEX: � PHYSICIAN NAME, � en-USADDRESS: PHYSICIAN INFORMATION: � PHYSICIAN222S � TELEPHONE NO: SECTION B: � EST. LENGTH OF NEED: � DIAGNOSIS CODES: � QUESTION SECTION: � NAME OF PERSON � ANSWERING SECTION B QUESTIONS: � SECTION C: � NARRATIVE � DESCRIPTION OF � EQUIPMENT & COST: � SECTION D: � PHYSICIAN � ATTESTATION: � PHYSICIAN SIGNATURE � AND � DATE: � (May be completed by the supplier)If this is an initial certification for this patient, indicate this by placing date (MM/DD/YY) needed initially in the space TYPE/marked 223INITIAL.224 If this is a revised certification (to be completed when the physician changes the order, based on the patient222s changing clinical needs), indicate the initial date needed in the space marked 223INITIAL,224 and indicate the recertification date in the space marked 223REVISED.224 If this is a recertification, indicate the initial date needed in the space marked 223INITIAL,224 and indicate the recertification date in the space marked 223RECERTIFICATION.224 Whether submitting a REVISED or a RECERTIFIED CMN, be sure to always furnish the INITIAL date as well as the REVISED or RECERTIFICATION date.Indicate the patient222s name, permanent legal address, telephone number and his/her as it appears on his/her Medicare card and on the claim form.Indicate the name of your company (supplier name), address and telephone number along with the Medicare Supplier Number assigned to you by the National Supplier Clearinghouse (NSC) or applicable National Provider Identifier (NPI). If using the NPI Number, indicate this by using the qualifier XX followed by the 10-digit number. If using a legacy number, e.g. NSC number, use the qualifier 1C followed by the 10-digit number. (For example. 1Cxxxxxxxxxx)Indicate the place in which the item is being used, i.e., patient222s home is 12, skilled nursing facility (SNF) is 31, End Stage Renal Disease (ESRD) facility is 65, etc. Refer to the DMERC supplier manual for a complete list.If the place of service is a facility, indicate the name and complete address of the facility.List all procedure codes for items ordered. Procedure codes that do not require certification should not be listed on the CMN. Indicate patient222s date of birth (MM/DD/YY) and sex (male or female); height in inches and weight in pounds, if requested. Indicate the PHYSICIAN222S name and complete mailing address. Accurately indicate the treating physician222s Unique Physician Identification Number (UPIN) or applicable National Provider Identifier (NPI). If using the NPI Number, indicate this by using the qualifier XX followed by the 10-digit number. If using UPIN number, use the qualifier 1G followed by the 6-digit number. (For example. 1Gxxxxxx)Indicate the telephone number where the physician can be contacted (preferably where records would be accessible pertaining to this patient) if more information is needed.(May not be completed by the supplier. While this section may be completed by a non-physician clinician, or a Physician employee, it must be reviewed, and the CMN signed (in Section D) by the treating practitioner.)Indicate the estimated length of need (the length of time the physician expects the patient to require use of the ordered item) by filling in the appropriate number of months. If the patient will require the item for the duration of his/her life, then enter 22399224.In the first space, list the diagnosis code that represents the primary reason for ordering this item. List any additional diagnosis codes that would further describe the medical need for the item (up to 4 codes).This section is used to gather clinical information to help Medicare determine the medical necessity for the item(s) being ordered. Answer each question which applies to the items ordered, checking 223Y224 for yes, 223N224 for no, or 223D224 for does not apply. If a clinical professional other than the treating physician (e.g., home health nurse, physical therapist, dietician) or a physician employee answers the questions of Section B, he/she must print his/her name, give his/her professional title and the name of his/her employer where indicated. If the physician is answering the questions, this space may be left blank.(To be completed by the supplier)Supplier gives (1) a narrative description of the item(s) ordered, as well as all options, accessories, supplies and drugs; (2)the supplier222s charge for each item(s), options, accessories, supplies and drugs; and (3) the Medicare fee scheduleallowance for each item(s), options, accessories, supplies and drugs, if applicable.(To be completed by the