Certification of Medical Necessity U.S. Department of Labor Employment Standards Administration Office of Workers' Compensation Programs Division of Coal Mine Workers' Compensation Completion of this form and prior approval is required for the Department of Labor to authorize reimbursement of charges for OMB No.:1215-0113 equipment, scheduled pulmonary rehabilitation services and home nursing care (30 U.S.C. 901 at seq. and 20 CFR 725.705 and Expires: 10-31-2011 725.706). Authorization covers a maximum period of one (1) year. Fill in all applicable items. (See DOL Reimbursement Standards under item eleven (11)). This form must be signed and dated by the treating physician. Collection of this information is required to obtain a benefit. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. 1. & 2. Patient's Name and Mailing Address 3. Telephone Number 4. Social Security Number 5. Date of Birth 6a. Date(s) of last hospitalization 6b. Condition(s) treated while in hospital From: To: : 7. Pulmonary Condition(s) for which this prescription is written: 8a. Type of Prescription Original (New) 8b. Requested Duration of Prescription for DME, Home Nursing or Pulmonary Rehabilitation Recertification (Renewal) Beginning Date: Ending Date: 9. EQUIPMENT OR SERVICE PRESCRIBED (SEE NO. 11, REVERSE, FOR CORRESPONDING REIMBURSEMENT STANDARDS) 9a. Oxygen Delivery Equipment (11 b.) Prescription: Flow Rate (L/M) Tank 02 With Flowmeter and Humidifier Est. Hrs./Day 02 Concentrator 02 Liquid System Portable Unit (Gaseous) 02 Liquid System With Portable Liquid 9b. Other DME 9c. Prescription for Medical Services Manual Hospital Bed (11 c.) Pulmonary Rehabilitation Services (See 11 e.) Semi-electric Hospital Bed (11 c.) Wheelchair (11 f.) Level: Nebulizer with Motor (11 a.) Other (Explain in item no. 12.) Home Nursing Care (See 11 d.) 10. Objective Test Results -Original or Certified copies of all lab reports must be attached, including tracing for each PFT. The following data (10A through 10D for a PFT; 10E through 10I for an ABG) MUST BE reported below OR on the attached lab report. (Note: Patient's condition is considered ACUTE if test was taken during a hospitalization.) A. Pulmonary Function Test Date of test: Pt.'s condition: Acute B. Check as appropriate (if "poor", explain in No. 12 'Additional Comments") Miner's Cooperation: Good Fair Poor Miner's ability to understand instructions and follow directions: Predicted Bronchodilation Before After FEV, L/BTPS Yes C. Was equipment calibrated before the test? Poor No On 0 @ 2 LPM D. Testing Facility Name and Address: name: line 1: line 2: FVC L/BTPS F. Air Intake: E. Arterial Blood Gas Test Date of test: Pt.'s condition: G. Time Sample Drawn On room air PCO2 PH Yes Chronic PO2 Time Sample Analyzed Iced Acute Results: Fair Good Chronic Results : (Best Effort) No H. Was equipment calibrated before the test? I. Testing Facility Name and Address line 1: line 2: Yes No Name: city: state: American LegalNet, Inc. www.FormsWorkflow.com zip: Form CM-893 Rev. April 2008 DOL Reimbursement Standards 11a. For Home 02 delivery equipment: requires a pO2 value of 60 mmHg or less on room air during a chronic state with corresponding pC02 and pH values. If the ABG is done while the patient is on O2, the pO2 standard = 80 mmHg for all oxygen equipment (See 11f.). All medical evidence to support your request will be considered. 11b. Hospital bed: must be justified by PF test results indicating an FEV1 equal to or less than 40% of predicted, or chronic hypoxia (p02 of 55 mmHg or less). 11c. Prescriptions for home care: must include objective test results or comparable clinical data, explanation why the patient is homebound, and a specific schedule of services to be rendered, including the total number and frequency of prescribed visits. Indicate the type of medical professional (PA, RN, LPN, RT) providing care. Use number 12, below, and/or attach separate sheet. 11d. Prescription for pulmonary rehabilitation services: must include objective test results that justify extent (i.e., level) of rehabilitation prescribed. All services for pulmonary rehabilitation must be categorized by Impairment Level (AMA - Guides to the Evaluation of Permanent Impairment, 2nd Ed. 1984). Also, all pulmonary rehabilitation protocols must be prior-approved. Use number 12, below, and/or attach separate sheet. 11e. Wheel chairs: are not a commonly covered item. Requests must include medical support data and will be evaluated individually. Data must support the wheelchair need because of a severe pulmonary impairment. 11f. ALL CMN supportive test results: must be dated 2 months or less prior to prescription for services. Recertification services for home nursing care and pulmonary rehabilitation services must be reviewed yearly or at the expiration date. NOTE: Prescription for indefinite services or those without required objective test data will be returned for specific information. If your request is rejected because your patient's medical condition does not meet DOL reimbursement requirement standards you may submit other medical evidence to support your prescription request. All evidence will be considered. 12. Comments: 13. PHYSICIAN/PROVIDER INFORMATION a. Physician's Name, Address and Phone Number (print or type) b. Are you the patient's regular physician or are you actively treating this patient? If NO, explain why you are prescribing the equipment or services on this form. c. Date of Visit (the date you examined the Patient and made the decision for this prescription): d. Date that the prescribed treatment or service is authorized to begin: e. I certify that I am the current treating physician (or have provided an explanation in 13b. above) and that the prescribed equipment and/or services on this form are medically necessary for treating this patient's condition. Any statement on my letterhead attached here to, has been reviewed and signed by me. I understand that any falsification, omission, or concealment of medical fact may subject me to civil or criminal liability. Physician's Original Signature (Do not use stamp) Please forward this completed form to the DOL/DCMWC Office which maintains the patient's Black Lung Claim. For further information call TOLL FREE: 1-800-638-7072. Date f. Provider's Name, Address, Phone No., and PROVIDER NO.: PRIVACY ACT The following information is provided in accordance with the Privacy Act of 1974. (1) Collection of this information is authorized by the Black Lung Benefits Act (30 USC 901 et seq.) (2) The information in this form will be used to ensure that the program covers the medical treatment prescribed and to ensure accurate medical provider information for payment of medical bills. Disclosure of beneficiary's social security number and completion of this form are voluntary. Failure to provide the requested information and documentation may result in bill payment delays or denial. (3) information may be used by other agencies, government contractors or persons in handling matters related, directly or indirectly, to processing this form. (4) Furnishing all requested information will facilitate accurate and timely payment of medical services to the provider. Public Burden Statement We estimate that it will take an average of 20-40 minutes to complete this collection of information, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding these estimates or any other aspect of this collection of information, including suggestions for reducing this burden, send them to the Division of Coal Mine Workers' Compensation, U.S. Department of Labor, Room N-3464, 200 Constitution Avenue, N.W., Washington, DC. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE American LegalNet, Inc. www.FormsWorkflow.com