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Apnea Monitors, Pediatric

|Question |Reply or required information |

|Has the infant had an apparent life threatening event (ALTE) defined as an episode |Select from drop down: |

|that is frightening to observe and is characterized by some combination of: |Yes or No |

|Apnea, Color change, Marked change in muscle tone, Choking, Gagging | |

| | |

|If yes, please describe how long the episode lasted and if associated with | |

|bradycardia (heart rate less than 80 beats per minute) and cyanosis | |

|Does the infant have a tracheostomy or anatomic abnormality that makes them |Select from drop down: |

|vulnerable to airway compromise? |Yes or No |

|Does the infant have a neurologic or metabolic disorder effecting respiratory |Select from drop down: |

|control? |Yes or No |

|Does the infant have chronic lung disease (i.e. bronchopulmonary dysplasia) |Select from drop down: |

|requiring |Yes or No |

|Supplemental oxygen, | |

|Continued positive airway pressure, or | |

|Mechanical ventilation | |

|Is the infant a sibling of sudden infant death (SID) victim? |Select from drop down: |

| |Yes or No |

|Have the parents and other caregivers been trained in observation of the infant, |Select from drop down: |

|operation of the monitor and infant cardio-pulmonary resuscitation (CPR)? |Yes or No |

| |

|REAUTHORIZATION—above questions and: |

|Does the pediatric home apnea monitoring event recording include respiratory |Select from drop down: |

|rate, pattern and heart rate over a 30 day period? |Yes or No |

|Has the physician established a plan for periodic review and termination? |Select from drop down: |

| |Yes or No |

|Date range: | |

|Anticipated discharge date: | |

UV/Light therapy

|Question |Reply or required information |

|Why does the patient require UV/Light therapy? | |

Bath/Shower Chair

|Question |Reply or required information |

|What reason does the patient require a Bath/Shower chair? | |

Bed Cradle

|Question |Reply or required information |

|Is a bed cradle needed to prevent contact with bed coverings? |Select from drop down: |

| |Yes or No |

BiPAP

|Question |Reply or required information |

|Is this a request for BiPAP or auto-adjusting CPAP (APAP, DPAP)? Specify device | |

|Does the patient have a clinical disorder characterized as a restrictive thoracic |Select from drop down |

|disorder? |Yes, No, orNA |

|If yes, does the patient have either a progressive neuromuscular disease or severe | |

|thoracic cage abnormality? If yes, specify | |

|If available, what is the patient’s arterial blood gas (done while the patient is | |

|awake on their usual FIO2)? | |

|What is the patient’s oxygen saturation (based on the patient’s sleep oximetry while| |

|breathing the patient’s usual FIO2)? | |

|If they have a progressive neuromuscular disease, is their forced vital capacity < | |

|than 50%, or their maximal inspiratory pressure less than 60cm H20? | |

|Does chronic obstructive pulmonary disease not contribute significantly to the |Select from drop down |

|patient’s pulmonary limitation? |Yes or No |

|Does the patient have COPD? |Select from drop down |

| |Yes, No, or NA |

|If yes, is the patient’s arterial blood gas PaCO2, (done while awake and breathing |Select from drop down |

|the patient’s usual FIO2) > than or equal to 52 mm Hg? |Yes or No |

|Does the patient’s sleep oximetry demonstrate oxygen saturation < than or equal to |Select from drop down |

|88% for at least five continuous minutes, done while breathing oxygen at 2 LPM or |Yes or No |

|the patient’s usual FIO2 (whichever is higher)? | |

|Prior to initiating therapy with BiPAP, has Obstructive Sleep Apnea (OSA) and |Select from drop down |

|treatment with a continuous positive airway pressure device (CPAP) been considered |Yes or No |

|and ruled out? | |

|Does the patient have Central Sleep Apnea (CSA) or Complex Sleep Apnea (CompSA)? |Select from drop down |

| |Yes, No, or NA |

|If yes, what is the AHI? | |

|Are the central apneas/hypopneas > than 50% of the total apneas/hypopneas? |Select from drop down |

| |Yes or No |

|Are the central apneas or hypopneas > than or equal to 5 times per hour? |Select from drop down |

| |Yes or No |

|Does the patient have symptoms of either excessive sleepiness or disrupted sleep? |Select from drop down |

| |Yes or No |

|Prior to initiating therapy to treat Central Sleep Apnea or Complex Sleep Apnea, has|Select from drop down |

|the patient had a complete facility based attended polysomnogram confirming the |Yes or No |

|diagnosis? | |

|Has CPAP been ruled out as effective therapy if either CSA or OSA is a component of |Select from drop down |

|the initially observed sleep-associated hypoventilation? |Yes or No |

|Has significant improvement of sleep associated hypoventilation been noted using |Select from drop down |

|BiPAP, APAP or DPAP while breathing the patient’s usual FiO2 on the settings |Yes or No |

|prescribed for home use? | |

|Prior to initiating BiPAP therapy for the patient’s medical condition, has the |Select from drop down |

|patient tried a CPAP device and was found to be ineffective during the initial 3 |Yes or No |

|month trial? | |

|Was a CPAP device used for > than 3 months and then found to be ineffective? |Select from drop down |

| |Yes or No |

|Has the patient failed a previous 3 month trial of PAP therapy (including patient |Select from drop down |

|non compliance)? |Yes or No |

|If the patient has failed, have they now had a face to face clinical re-evaluation |Select from drop down |

|by the treating physician to determine the cause of the failure to respond to PAP |Yes or No |

|therapy? | |

|Did they have a repeat sleep test in a facility-based setting (Type 1 study)? |Select from drop down |

| |Yes or No |

|Is BiPAP without a back up rate feature, requested to treat obstructive sleep apnea |Select from drop down |

|because CPAP has been tried and proven ineffective or not tolerated? |Yes or No |

|Has the referral source been instructed to fax the diagnostic sleep study (including|Select from drop down |

|AHI, or RDI, and titration if done) along with the physician’s prescription? |Yes or No |

|Medicare Advantage Members-See below | |

|Is BiPAP without a back up rate feature, requested to treat obstructive sleep apnea | |

|because CPAP has been tried and proven ineffective or not tolerated? | |

|How was the diagnosis of obstructive sleep apnea (OSA) determined, specify: | |

|Polysomnogram (Type I study) performed in a facility-based laboratory, or | |

|Home Sleep Test (HST) (Type II or III, IV, Other) | |

|If performed in the facility, does the study include sleep staging, a FOG, FMG, FCG | |

|testing? | |

|Does the study include airflow, respiratory effort and oxygen saturation by | |

|oximetry? | |

|For home sleep testing: | |

|What device was used | |

|What is the FCG | |

|Heart rate | |

|Oxygen saturation | |

|Has the referral source been instructed to fax the diagnostic sleep study, other |Select from drop down |

|testing as noted in either the facility or home, along with the physician’s |Yes or No |

|prescription? | |

|REAUTHORIZATION—see below |

|Has the patient been using the device for 3 months? |Select from drop down |

| |Yes or No |

|When was the patient seen by the physician for a clinical re evaluation after | |

|starting PAP therapy? | |

|Has the physician determined the patient is benefitting from PAP therapy? |Select from drop down |

| |Yes or No |

|Per download from the device, Smart Card or other data card, how many hours per | |

|night in the patient using the device? | |

|During the last 30 days of the 3 month trial period how many nights did the patient | |

|use the device? | |

|Does the physician’s re evaluation include documentation of improvement in | |

|subjective symptoms? If yes, specify | |

Blood Glucose Monitors

|Question |Reply or required information |

|Has the patient’s physician submitted a Certificate of Medical Necessity? | |

|Is the patient being treated for diabetes? | |

|Has the ordering physician prescribed the monitor and accessories needed, including | |

|testing frequency? | |

|Who is capable of being trained in using the glucometer and in monitoring the | |

|patient? | |

|Is the device for home use? | |

|What items are ordered? | |

|Based on the patient’s medical condition, how often is the patient to test? | |

|Is the physician’s order signed and dated? | |

|What is the start date of the order? (required if the start date is different than | |

|the signature date) | |

|Is the patient insulin or non-insulin dependent? | |

|Is a glucometer with special features requested? | |

|Has the physician certified the patient has a severe visual impairment (defined as | |

|best corrected visual acuity is 20/200 or worse) that prevents the use of a standard| |

|blood glucose monitor? | |

|Has the physician certified that the patient has a manual dexterity impairment | |

|requiring the use of a special features glucometer? | |

|If yes, what is the nature of the physical impairment? (request for a special | |

|feature glucometer for patients with manual dexterity impairments is not dependent | |

|upon a visual impairment) | |

|Is this a request for a replacement glucometer? | |

|Why does the patient need a replacement? | |

| |

|Medicare Advantage Members-above questions and: |

|Has the patient or caregiver successfully completed or is scheduled to begin to | |

|train to use the monitor, test strips, and lancing devices? | |

|Is the patient or caregiver capable of using the test results to assure the patient | |

|has appropriate glycemic control? | |

|If a special feature glucometer is requested, does the patient have a severe visual | |

|impairment (i.e. best corrected visual acuity of 20/200 or worse in both eyes)? | |

|Has the patient’s testing frequency order changed, if so, has this been verified by | |

|physician order? | |

Breast Pump

|Question |Reply or required information |

|What reason does the patient require a Breast Pump? | |

|Will there be a separation between the mother and baby? | |

|What type of pump is being requested? | |

Cold Therapy

|Question |Reply or required information |

|What reason does the patient require a cold therapy? | |

Conductive Garment

|Question |Reply or required information |

|Is the conductive garment used with a TENS unit? |Select from drop down |

| |Yes or No |

|Is the conductive garment FDA approved? |Select from drop down |

| |Yes or No |

|Has the physician prescribed the use of a conductive garment? |Select from drop down |

| |Yes or No |

|Does the patient have a large area or multiple sites to be stimulated and the |Select from drop down |

|stimulation would have to be delivered so frequently that pain cannot be managed by |Yes or No |

|using conventional electrodes, adhesive tapes or lead wires? | |

|Is the patient’s chronic intractable pain located in an area that is inaccessible |Select from drop down |

|with the use of conventional electrodes? |Yes or No |

|Does the patient have a medical condition (i.e., skin condition) that prevents the |Select from drop down |

|use of conventional electrodes? |Yes or No |

|Does the patient require electrical stimulation beneath a cast? |Select from drop down |

| |Yes or No |

Continuous Glucose Monitoring (CGM)

|Question |Reply or required information |

|Does the patient have Type I diabetes or insulin dependent Type II diabetes? specify| |

|Has the patient had failed control despite adherence to a treatment regime which |Select from drop down: |

|includes: |Yes or No |

|4 or more finger sticks per day, or | |

|3 or more insulin injections per day, and | |

|Prior use of the 72 hour monitor | |

|Does the patient have recurrent, unexplained, severe, symptomatic episodes of |Select from drop down: |

|hypoglycemia that puts the patient or others at risk? |Yes or No |

|What are the blood glucose levels? | |

|Is the patient insulin dependent and pregnant whose diabetes is poorly controlled | |

|with any of the following clinical situations (select all that apply): | |

|Unexplained hypoglycemic episodes | |

|Hypoglycemic unawareness | |

|Suspected postprandial hyperglycemia | |

|Recurrent diabetic ketoacidosis | |

|Does the insulin dependent pregnant patient do multiple daily insulin injections |Select from drop down: |

|with frequent monitoring? specify |Yes or No |

|What model of CGM is requested? | |

|Is the model requested an external insulin pump with wireless communication to a | Select from drop down: |

|compatible continuous glucose monitoring sensor/transmitter? |Yes or No |

|Is this to replace existing functioning equipment to upgrade to wireless technology?|Select from drop down: |

| |Yes or No |

Commodes

|Question |Reply or required information |

|What type of commode is being requested (i.e., 3-1 or drop arm), (3-1 commode has a | |

|300-lb. maximum weight limit / drop arm commode has up to a 300-lb. maximum weight | |

|limit.)? | |

|Height | |

|Weight | |

|Ambulatory status | |

|Is the patient confined to a bed, room, or one floor of their home with out a | |

|bathroom? | |

Toilet Seat

|Question |Reply or required information |

|What reason does the patient require a raised toilet seat? | |

CPAP

|Question |Reply or required information |

|Is this a request for a CPAP device--Continuous Positive Airway Pressure Device | |

|(includes C-Flex and CPAP with expiratory pressure relief (EPR), specify device | |

|What comorbidities does the patient have? | |

|How was the diagnosis of obstructive sleep apnea (OSA) determined, specify: (NA for | |

|Medicare Advantage members) | |

|Polysomnogram (Type I study) performed in a facility-based laboratory, or | |

|Home Sleep Test (HST) (Type II or III) | |

|Does the patient have: Excessive daytime sleepiness or drowsiness, Impaired | |

|cognitive ability | |

|Mood disorders, Insomnia | |

|If yes, please specify | |

|Does the patient have Hypertension, Ischemic heart disease, Stroke | |

|If yes, please specify | |

|What is the AHI (Apnea-Hypopnea Index) or RDI (Respiratory Disturbance Index)? | |

|Is the request for CPAP for a pediatric patient? | |

|If, yes, does the patient have excessive daytime sleepiness, behavior problems, or | |

|hyperactivity? | |

|If yes, please specify | |

|What is the AHI? | |

|Has a titration study been done to achieve optimal CPAP pressure to eliminate sleep | |

|related breathing events in all stages and positions of sleep? | |

|Has the referral source been instructed to fax the diagnostic sleep study (including| |

|AHI, or RDI, and titration if done) along with the physician’s prescription? | |

|Has the patient failed a previous 3 month trial of PAP therapy (including patient |Select from drop down |

|non compliance)? |Yes or No |

|If the patient has failed, have they now had a face to face clinical re-evaluation |Select from drop down |

|by the treating physician to determine the cause of the failure to respond to PAP |Yes or No |

|therapy? | |

|Did they have a repeat sleep test in a facility-based setting (Type 1 study)? |Select from drop down |

| |Yes or No |

|Is C-Clex or CPAP with EPR ordered over standard CPAP to improve patient comfort and|Select from drop down |

|compliance? |Yes or No |

|Medicare Advantage Members-above questions and: | |

|How was the diagnosis of obstructive sleep apnea (OSA) determined, specify: | |

|Polysomnogram (Type I study) performed in a facility-based laboratory, or | |

|Home Sleep Test (HST) (Type II or III, IV, Other) | |

|If performed in the facility, does the study include sleep staging, a FOG, FMG, FCG | |

|testing? | |

|Does the study include airflow, respiratory effort and oxygen saturation by | |

|oximetry? | |

|For home sleep testing: | |

|What device was used? | |

|What is the FCG? | |

|Heart rate? | |

|Oxygen saturation? | |

|REAUTHORIZATION—see below |

|Has the patient been using the CPAP device for 3 months? | |

|When was the patient seen by the physician for a clinical re evaluation after | |

|starting PAP therapy? | |

|Has the physician determined the patient is benefitting from PAP therapy? | |

|Per download from the device, Smart Card or other data card, how many hours per | |

|night in the patient using the device? | |

|During the last 30 days of the 3 month trial period how many nights did the patient | |

|use the device? | |

|Does the physician’s re evaluation include documentation of improvement in | |

|subjective symptoms of OSA? If yes, specify | |

|Does the re evaluation include documentation showing objective data related to |Select from drop down |

|patient adherence to the PAP therapy? |Yes or No |

|Has the physician determined that use of C-Clex or CPAP with EPR over standard CPAP |Select from drop down |

|would improve patient compliance? |Yes or No |

CPAP/BIPAP Mask and Supplies

|Question |Reply or required information |

|Has the patient previously qualified for a CPAP or BIPAP? |Select from drop down: |

| |Yes |

| |No |

|Does the patient have a CPAP/BIPAP currently in the home? |Select from drop down: |

| |Yes |

| |No |

Continuous Passive Motion Device (CPM)

|Question |Reply or required information |

|Did the patient have a total knee replacement (either unilateral or bilateral)? |Select from drop down: |

| |Yes or No |

|Did the patient have an anterior cruciate ligament (ACL) reconstruction (either |Select from drop down: |

|bilateral or unilateral)? |Yes or No |

|Is CPM ordered for treatment of all other applications of the knee (e.g. repairs of |Select from drop down: |

|cartilaginous defects such as autologous chondrocyte transplantation)? |Yes or No |

|Is CPM ordered in the home setting for treatment of all other joints such as hip, | Select from drop down: |

|shoulder, elbow, metacarpals, interphalangeal joints, or metatarsals? |Yes or No |

|Was CPM applied immediately after surgery? |Select from drop down: |

| |Yes or No |

|What settings are ordered (range of motion, speed)? | |

|REAUTHORIZATION –above questions and: |

|Has the patient received CPM therapy for 14 days post operatively yet? |Select from drop down: |

| |Yes or No |

|What is the current range of motion tolerated by the patient? | |

|Date range | |

|Anticipated discharge date | |

Cushion-Gel

|Question |Reply or required information |

|Is the cushion required for a wheelchair? |Select from drop down: |

| |Yes or No |

|Is the patient at risk for pressure ulcers? |Select from drop down: |

| |Yes or No |

|Does the patient currently have a pressure ulcer? |Select from drop down: |

| |Yes or No |

|Will use of the cushion provide additional support for the patient? |Select from drop down: |

| |Yes or No |

|Does the patient have absent or impaired sensation at the point of contact with the |Select from drop down: |

|chair? |Yes or No |

Diabetic Shoes and Inserts

|Question |Reply or required information |

|Does the patient have a diagnosis of diabetes? |Select from drop down: |

| |Yes |

| |No |

|Is the patient under a comprehensive treatment plan for the diabetic condition? |Select from drop down: |

| |Yes |

| |No |

|Does the patient have one or more of the following conditions in one or both feet? |Select from drop down: |

|previous amputation of the foot or part of the foot |Yes |

|foot deformity with a potential for ulceration |No |

|callus formation OR a history of callus formation with peripheral neuropathy | |

|a history of previous foot ulceration | |

|poor pedal OR lower extremity circulation. | |

|Has the MD certified the above information? |Select from drop down: |

| |Yes or No |

|Has the patient received shoes or inserts within the last year? |Select from drop down: |

| |Yes or No |

Enteral Formulas

|Question |Reply or required information |

|What is the patient’s diagnosis? | |

|What is the patient’s date of birth? | |

|Height | |

|Weight | |

|Is this an inherited disease of amino acid, organic acid, carbohydrate or fat | |

|metabolism? | |

|Does the patient have a condition of malabsorption originating from congenital | |

|defects present at birth or acquired during the neonatal period? | |

|What has name and brand of product has the physician prescribed? | |

|How is the formula to be administered (nasogastric tube, gastrostomy or jejunostomy | |

|tube)? | |

|Is the formula administered intermittently or continuously? | |

|Is the product taken orally or by pump? | |

|Medicare Advantage Members—See Below: |

|Does the patient have a permanent non function or disease of the structures that | |

|normally permit food to reach the small bowel? If yes, specify | |

|Does the patient have a disease of the small bowel which impairs digestion and | |

|absorption of an oral diet? If yes, specify | |

|Would dietary adjustment and/or oral supplements provide the patient with adequate | |

|nutrition? | |

|Does the patient have a partial impairment that impacts adequate nutrition? If yes, | |

|specify | |

|Is the patient receiving the feedings through a feeding tube? | |

|Has the physician determined the patient has a condition of long and indefinite | |

|duration (at least 3 months)? | |

|Without enteral formula, will the patient be unable to obtain sufficient nutrients | |

|to maintain an appropriate weight? | |

|Height | |

|Weight | |

|REAUTHORIZATION—See Below: |

|Weight | |

|Has the patient had a weight loss or gain while on enteral therapy? | |

|If the patient has had a weight loss while on enteral therapy, has there been a | |

|change in the patient’s medical condition? If yes, specify | |

External Insulin Infusion Pump

|Question |Reply or required information |

|What model of insulin pump is the physician ordering? | |

|are special features requested, if so specify | |

|specify the number of infusion sets required including the type, needle vs. cannula,| |

|number of cartridges and syringes | |

|Is the request for a peritoneal or implantable insulin infusion pump |Select from drop down: |

| |Yes or No |

|Is the pump requested for a first time user? |Select from drop down: |

| |Yes or No |

|Has the patient seen their medical provider 4 times in the past year? |Select from drop down: |

| |Yes or No |

|Has the patient completed a comprehensive diabetic education program within the past|Select from drop down: |

|2 years? |Yes or No |

|If not, is the request for a replacement pump and education was completed prior to |Select from drop down: |

|beginning pump therapy? (See additional section on Replacement Pumps) |Yes or No |

|Does the patient self inject insulin 3 times a day or more? |Select from drop down: |

| |Yes or No |

|Has the patient had frequent self-adjustments of their insulin dose over the past 6 |Select from drop down: |

|months? |Yes or No |

|Has the patient been self testing at least 4 times a day for the past 2 months? |Select from drop down: |

| |Yes or No |

|Is the patient’s Glycosylated hemoglobin level (HbA1c) > than 7.0%? Specify | |

|Has the patient had recurrent episodes of diabetic ketoacidosis and/or hypoglycemia |Select from drop down: |

|resulting in recurrent and/or prolonged hospitalizations? |Yes or No |

|Does the patient have a history or recurring hypoglycemia or severe glycemic |Select from drop down: |

|excursions? |Yes or No |

|Does the patient have a history of wide fluctuations in blood glucose before meals |Select from drop down: |

|(i.e. are pre meal blood levels commonly > 140 mg/dL)? |Yes or No |

|Does the patient experience “Dawn phenomenon” where fasting blood sugars frequently |Select from drop down: |

|exceed 200 mg/dL? |Yes or No |

|Is the patient in a pre-conception or pregnancy state to reduce the incidence of |Select from drop down: |

|fetal mortality or anomaly? |Yes or No |

|Is this a patient who has been successfully using a continuous insulin pump prior to|Select from drop down: |

|enrollment and has documented frequency of glucose testing on average of at least 4 |Yes or No |

|times per day? | |

|Replacement Pumps |

|Has the patient had comprehensive diabetic education prior to beginning pump | |

|therapy? | |

|Is a replacement pump requested due to (specify) | |

|the patient’s pump out of warranty (average 4 years) with verification | |

|malfunctioning and cannot be refurbished | |

|the current pump no longer meets the patient’s medical needs, specify | |

|an upgrade due to new technology | |

|For Medicare Advantage Members | |

|What is the patient’s C-peptide level? | |

|Does the patient have documented renal insufficiency? |Select from drop down: |

| |Yes or No |

|What is the creatinine clearance level? | |

|What is the fasting C-peptide level | |

|What is the fasting blood sugar level that was obtained at the same time as the | |

|C-peptide level? | |

|What is the patient’s beta cell autoantibody test result? |Select from drop down: |

| |Positive or Negative |

|Has the patient completed a comprehensive diabetic education program? |Select from drop down: |

| |Yes or No |

|Is this a patient who has been on a continuous insulin pump prior to enrollment in |Select from drop down: |

|Medicare and has documented frequency of glucose testing on average of at least 4 |Yes or No |

|times per day during the month prior to Medicare enrollment? | |

|REAUTHORIZATION |

|Has the patient seen and been evaluated by the treating physician at least every 3 |Select from drop down: |

|months? |Yes or No |

|Does the patient’s physician manage multiple patients on subcutaneous insulin |Select from drop down: |

|infusion therapy and work closely with a team of nurses, diabetic educators and |Yes or No |

|dieticians knowledgeable in the use of subcutaneous insulin infusion therapy? | |

Hospital Beds

|Question |Reply or required information |

|What type of bed is requested, specify: | |

|Standard fixed height, Variable height, Semi electric, | |

|Heavy duty, Other | |

|Type of rails? (i.e. full or half length) | |

|Is this a request for an intuitional-type hospital bed? |Select from drop down |

| |Yes or No |

|Is this a request for a total electric hospital bed? |Select from drop down |

| |Yes or No |

|Is this a request for an Enclosure Bed? |Select from drop down |

| |Yes or No |

|Does the patient have a condition that requires frequent re-positioning in ways that|Select from drop down |

|cannot be accomplished by a regular bed? |Yes or No |

|Does the patient require the head or upper body be elevated 30 degrees or less? |Select from drop down |

| |Yes or No |

|Does the patient require positioning to alleviate pain? |Select from drop down |

| |Yes or No |

|Does the patient require that the head of the bed be elevated more than 30 degrees |Select from drop down |

|due to conditions such as, but not limited to: |Yes or No |

|Congestive Heart Failure | |

|Chronic Pulmonary Disease | |

|Problems with aspiration | |

|Does the patient require trapeze equipment that cannot be attached to an ordinary |Select from drop down |

|bed? (Refer to Bed Accessories template for additional information) |Yes or No |

|Does the patient require adjustable height in order to transfer from the bed to | Select from drop down |

|chair, wheelchair or to a standing position? |Yes or No |

|Does the patient require frequent changes in position and/or have an immediate need |Select from drop down |

|for a change in body position? |Yes or No |

|Does the patient need a heavy duty or extra heavy duty bed? | |

|What is the patient’s weight? | |

|What is the patient’s height? | |

|REAUTHORIZATION—above questions and: |

|Date range: | |

|Anticipated length of use? | |

Foot Board

|Question |Reply or required information |

|What is the need for a foot board? | |

|Is the patient bedridden? | |

Lymphedema Pumps and Devices

|Question |Reply or required information |

|What is the etiology the lymphedema device is being ordered to treat? | |

|What other conservative treatments has the patient tried and failed in treating this| |

|condition? | |

|What type of pump/device is requested? (segmental, non segmental, gradient | |

|pressure) | |

|What type of sleeve is needed? | |

|Is there evidence of any of the following conditions, specify: | |

|Infection | |

|Venous or arterial occlusive disease | |

|Venous thrombosis | |

|Massive edema secondary to congestive heart failure | |

|Metastatic disease in the involved extremity | |

|Does the patient have a compression garment to wear for the affected extremity after|Select from drop down: |

|treatment? |Yes or No |

|What are the limb measurements (size and circumference of extremity?) | |

|For Medicare Advantage Members-above questions and: | |

|Has the patient undergone a 4 week trial of conservative treatment? | |

|Has the physician determined there was any improvement after the trial period? |Select from drop down: |

| |Yes or No |

|Has the patient failed previous treatment with all of the following: |Select from drop down: |

|Compression bandage system or compression garment (providing adequate gradient |Yes or No |

|compression) | |

|Exercise | |

|Elevation of the limb | |

|Does the patient have a diagnosis of chronic venous insufficiency (CVI) with 1 or |Select from drop down: |

|more venous stasis ulcers? |Yes or No |

|If yes, what is the location and how long has it been present? | |

|In treating a chronic venous stasis ulcer, has the patient had all of the following | |

|treatments: | |

|Compression bandage system or compression garment | |

|Appropriate dressings for the wound | |

|Exercise | |

|Elevation of the limb | |

|How often is progress monitored by the physician? | |

|What is the frequency and duration of use prescribed by the physician? | |

| | |

|REAUTHORIZATION-above questions and: |

|What are the limb measurements (size and circumference of extremity?) | |

|Have the patient and family received instruction on application and use of the |Select from drop down: |

|device? |Yes |

| |No |

|Are the patient and or caregiver able to provide an accurate return demonstration of|Select from drop down: |

|use of the device? |Yes |

| |No |

|In treating CVI, how has the venous stasis ulcer responded to treatment? (i.e. size | |

|of ulcer, wound bed, drainage) | |

|Date range: | |

|Anticipated discharge date: | |

Negative Pressure Wound Therapy (NPWT) Pumps

|Question |Reply or required information |

|Does the patient have a Stage III or Stage IV pressure ulcer, neuropathic ulcer |Select from drop down |

|(e.g., diabetic), venous or arterial insufficiency ulcer, or a chronic ulcer of |Yes or No |

|mixed etiology (i.e. present for 30 days or more? | |

|What other conservative wound therapies been attempted and failed including but not | |

|limited to: | |

|Application of moist dressings | |

|Has the patient had debridement of any necrotic tissue? |Select from drop down |

| |Yes or No |

|Has the patient had an evaluation and provision for adequate nutritional status |Select from drop down |

| |Yes or No |

|Patient co morbidities and current wound care: | |

|What are the wound measurements as recorded by the licensed medical professional | |

|(i.e. physician, RN, LPN RPT) | |

|Does the patient have ANY of the following conditions: (specify) |Select from drop down |

|a) Necrotic tissue with eschar is present in the wound bed, if debridement not |Yes or No |

|attempted | |

|b) Untreated osteomyelitis within the vicinity of the wound | |

|c) Cancer in the wound | |

|d) A fistula to an organ or body cavity is present within the vicinity of the wound | |

|If the patient has a Stage III or IV pressure ulcer | |

|Has the patient been appropriately turned and positioned? | Select from drop down |

| |Yesor No |

|How has the patient’s moisture and incontinence been managed appropriately? | |

|If the patient has a neuropathic ulcer: | |

|Has the patient been on a comprehensive diabetic management program |Select from drop down |

| |Yes or No |

|For foot ulcers, how has the pressure on the ulcer been reduced? | |

|For venous or arterial insufficiency ulcers | |

|Have compression bandages or garments been applied consistently? |Select from drop down |

| |Yes or No |

| Has the patient been encouraged to elevate the leg and ambulate? |Select from drop down |

| |Yes or No |

|For Medicare Advantage Members-above questions and: | |

|For high volume draining wounds (> than 90 ml of drainage per day) is a stationary |Select from drop down |

|pump with the largest capacity canister being used? |Yes or No |

| | |

|REAUTHORIZATION-above questions and: |

|How often is the wound being treated with NPWT assessed by the licensed medical |Daily |

|professional (i.e. physician, PA, RN, LPN or RPT)? |Twice a week |

| |Three times a week |

| |Other |

|Who performs the dressing changes using the vacuum assisted closure dressing sets? | |

|(Select) | |

|Physician, PA, RN, LPN, RPT | |

|Has the wound shown changes in dimensions and characteristic over the past 30 days? |Select from drop down |

| |Yes or No |

|Has the patient received treatment with NPWT for 4 months or longer? |Select from drop down |

| |Yes or No |

|If yes, how has the wound progressed toward healing? (describe size, wound bed | |

|characteristics, drainage) | |

Orthotics

|Question |Reply or required information |

|Has the equipment been ordered by a physician? |Select from drop down: |

| |Yes or No |

|Does the patient have one of the following diagnoses or similar condition: |Select from drop down: |

|strained or injured soft tissues |Yes or No |

|bony prominences | |

|deformed bones and joints | |

|rheumatoid nodules | |

|inflamed or chronic bursae | |

|dermatologic lesions secondary to deforming arthritis or biomechanical abnormality | |

|Does the patient require one of the following items: |Select from drop down: |

|Appliances essential to effective use of artificial limbs OR corrective braces |Yes or No |

|Braces for leg, arm, neck, back, shoulder | |

|Corsets for back or for use after special surgical procedures | |

|Harnesses essential to use of artificial limbs | |

|Hernia devices | |

|Splints for extremities | |

|Therapeutic shoes | |

Overlay-Alternating Pressure Pad

|Question |Reply or required information |

|What type of mattress or pad is requested? | |

|Can the patient make changes in body position without assistance to alleviate | |

|pressure? | |

|Is the patient considered either partially or fully immobile? | |

|Is the patient at risk for developing a pressure ulcer? | |

|Does the patient have a pressure ulcer(s)? | |

|What is the location? | |

|REAUTHORIZATION—above questions and below: | |

|Date range: | |

|If the pressure ulcer has deteriorated, has there been a change in the plan of care?| |

|How has the plan of care been modified to promote wound healing? | |

Oxygen

|Question |Reply or required information |

|Is the request for oxygen delivery via: | |

|Stationary unit, Portable unit, Transtracheal delivery | |

|Concentrator | |

|Has the treating physician prescribed oxygen for a severe lung disease or hypoxia |Select from drop down |

|related symptoms that may be expected to improve with oxygen therapy? |Yes or No |

|What is the physician prescribed flow rate? | |

|What is the estimate of the frequency? | |

|What is the duration of use? | |

|What is the duration of need? | |

|Can the flow be regulated and is not preset? |Select from drop down |

| |Yes or No |

|Does the regulator permit a flow rate > than 8L per minute in the home setting? |Select from drop down |

| |Yes or No |

|What is the PO2 level? | |

|What is the patient’s oxygen saturation rate? | |

|Does the patient have symptoms associated with oxygen deprivation such as impairment|Select from drop down |

|of cognitive processes, restlessness, or insomnia? |Yes or No |

|Was the initial oxygen saturation measurement obtained by pulse oximetry per |Select from drop down |

|physician order and performed by a qualified provider/supplier of laboratory |Yes or No |

|services? | |

|Portable Oxygen |

|Is the patient mobile in the home? |Select from drop down |

| |Yes or No |

|Was the qualifying blood gas study performed when the patient was: (specify) | |

|Awake (at rest) or During exercise | |

|Transtracheal Oxygen |

|Has the physician prescribed this delivery method? |Select from drop down |

| |Yes or No |

|Is the arterial oxygen tension equal to or less than 55mm Hg at 6-8L/min delivery |Select from drop down |

|rate? |Yes or No |

|Is the patient severely hypoxic and refractory (showing no improvement) to other | |

|methods of oxygen administration? | |

|Lightweight Oxygen Tank |

|Is a lightweight oxygen tank requested due to the patient’s frailty and inability to|Select from drop down |

|manage a standard tank? |Yes or No |

|Cluster Headache | |

|Is the request for oxygen to treat a diagnosis of cluster headaches? |Select from drop down |

| |Yes or No |

|Does the physician’s order for oxygen for cluster headaches reflect PRN oxygen? |Select from drop down |

| |Yes or No |

|Oxygen with CPAP and BiPAP |

|Is the request for oxygen to be used in conjunction with CPAP or BiPAP due to the |Select from drop down |

|patient having an underlying chronic obstructive disease (COPD), or |Yes or No |

|Pulmonary disease, and Demonstrates hypoxia? | |

|If the patient has obstructive sleep apnea (OSA), is the treatment toward relief of |Select from drop down |

|the obstruction with CPAP or BiPAP? |Yes or No |

|Oxygen for Nighttime Use |

|Does the physician’s order reflect that oxygen to be used every night? |Select from drop down |

| |Yes or No |

|Other |

|Has oxygen therapy been requested for any of the following conditions: |Select from drop down |

|Angina pectoris in the absence of hypoxemia |Yes or No |

|Dyspnea without cor pulmonale or evidence of hypoxemia | |

|Severe peripheral vascular disease resulting in clinically evident | |

|desaturation in one or more extremities | |

|Terminal illnesses that do not affect the respiratory system | |

|Was the physician’s order written with a PRN or as needed frequency? |Select from drop down |

| |Yes or No |

|Medicare Advantage Members-above questions and: |

|For Medicare Advantage Members enrolled as subjects in clinical trials | |

|approved by the Centers for Medicare and Medicaid Services and sponsored by | |

|the National Heart, Lung and Blood Institute (NHLBI): | |

|Is the arterial oxygen partial pressure measurement 56-65 mmHg or oxygen |Select from drop down |

|saturation at or above 89%? |Yes or No |

|REAUTHORIZATION-above questions and: |

|Was the oxygen saturation measurement obtained by pulse oximetry for the |Select from drop down |

|annual renewal of services by either the provider/supplier of laboratory |Yes or No |

|services or DME provider of oxygen and oxygen equipment? | |

|What is the oxygen saturation? | |

Portable Oxygen Concentrator

|Question |Reply or required information |

|Is the concentrator capable of delivering 85% or greater oxygen concentration? | |

|Does the unit operate on either AC or DC (automobile accessory outlet) power? | |

|Does the device provide at least 2 hours of remote portability at a minimum of 2 L | |

|per minute? | |

|What is the combined weight of the concentrator, battery/batteries? | |

|Is this device capable of functioning as a stationary concentrator operating 24 | |

|hours per day, 7 days per week? | |

|REAUTHORIZATION—see below questions | |

|When was the last O2 saturation done? | |

|Was the oxygen saturation measurement obtained by pulse oximetry for the annual | |

|renewal of services by either the provider/supplier of laboratory services or DME | |

|provider of oxygen and oxygen equipment? | |

|What is the oxygen saturation at rest? | |

|What is the oxygen saturation after exercise? | |

Pressure Reducing Support Surfaces

Group 2

|Question |Reply or required information |

|What type of mattress or pad is requested? | |

|Does the patient have multiple Stage II pressure ulcers located on the trunk and |Select from drop down: |

|pelvis? |Yes or No |

|Has the patient been on a comprehensive ulcer treatment program for at least 30 days|Select from drop down: |

|which has included the use of an appropriate Group I support surface (such as foam |Yes or No |

|mattress, gel overlay)? | |

|Have the ulcers deteriorated or remained the same over the past month? | |

|Does the patient have a large or multiple Stage III (full thickness tissue loss) |Select from drop down: |

|pressure ulcers? |Yes or No |

|Does the patient have a large or multiple Stage IV (deep tissue destruction) |Select from drop down: |

|pressure ulcers on the trunk or pelvis? |Yes or No |

|Has the patient had a recent myocutaneous flap or skin graft for a pressure ulcer on|Select from drop down: |

|the trunk or pelvis (surgery within the past 60 days)? |Yes or No |

|Has the patient been on a group 2 or 3 support surface immediately prior to a recent|Select from drop down: |

|discharge from a hospital or nursing facility (discharge within the past 30 days)? |Yes or No |

|In regards to the patient’s ulcer treatment program, have the patient and caregiver |Select from drop down: |

|been educated on the prevention and/or management of pressure ulcers? |Yes or No |

|How often is the patient’s condition monitored and evaluated by the nurse? | |

|How often is the patient turned and positioned? | |

|What is the wound care treatment for the patient? | |

|How is the patient’s moisture/incontinence managed? | |

|What nutritional interventions are in place to promote wound healing? | |

|REAUTHORIZATION-above questions and: | |

|Is the wound progressing toward healing as evidenced by decreased wound size, | |

|drainage and granulating wound bed? | |

|Date range: | |

|Anticipated discharge date: | |

Pressure Reducing Support Surface

Group 3

|Question |Reply or required information |

|What stage pressure ulcer does the patient have? | |

|Is the patient bed ridden? | |

|Would the patient require hospitalization without the air fluidized bed? | |

|What other conservative treatments been tried to promote wound healing over the past| |

|month? | |

|How often is the patient turned and positioned appropriately? | |

|What other support surfaces have been used to prevent new ulcer formation or reduce | |

|pressure on healing ulcers? | |

|If the wound has been infected, how was it treated? | |

|What nutritional interventions are in place to promote wound healing? | |

|Has the wound been debrided? |Select from drop down: |

| |Yes or No |

|Over the past month, what wound care treatment has been prescribed? | |

|Is there a trained adult caregiver available to assist the patient with activities |Select from drop down: |

|of daily living, fluid balance, skin care, repositioning, dietary needs, prescribed |Yes or No |

|treatments, and management and support of the bed system and problems such as | |

|leakage? | |

|How often does the physician re-evaluate the home care regimen? | |

|What other available alternative equipment has been considered and ruled out? | |

|REAUTHORIZATION-above questions and: |

|Is the wound progressing toward healing as evidenced by decreased wound size, | |

|drainage and granulating wound bed? | |

|Date range: | |

|Anticipated discharge date: | |

Prosthetic Devices

|Lower Limb Prostheses | |

|Question |Reply or required information |

|Does the patient demonstarate one of the following specific functional levels: |Select drop doqn: |

|Level 0: does not have the ability or potential to ambulate or transfer safely with |Yes |

|or without assistance and a prosthesis does not enhance their quality of life or |No |

|mobility. | |

|Level 1: Has the ability or potential to use a prosthesis for transfers or | |

|ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited | |

|household ambulator. | |

|Level 2: Has the ability or potential for ambulation with the ability to traverse | |

|low level environmental barriers such as curbs, stairs, or uneven surfaces. Typical | |

|of the limited community ambulator. | |

|Level 3: Has the ability or potential for ambulation with variable cadence. Typical | |

|of the community ambulator who has the ability to traverse most environmental | |

|barriers and may have vocational, therapeutic, or exercise activity that demands | |

|prosthetic utilization beyond simple locomotion. | |

|Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic | |

|ambulation skills, exhibits high impact, stress, or energy levels. Typical of the | |

|prosthetic demands of the child, active adult, or athlete. | |

|Is there documentation of the individual’s current functional capabilities and |Select from drop down: |

|expected functional potential, including an explanation for any existing difference?|Yes or No |

|IS the patient’s functional level “0”? |Select from drop down: |

| |Yes or No |

|Is there documentation of the patient’s functional level? |Select from drop down: |

| |Yes or No |

|Foot Prosthesis | |

|Does the patient meet one of the following catagories: | Select from drop down: |

|An external-keel SACH foot (HCPCS code L5970) or single-axis ankle/foot (HCPCS code |Yes |

|L5974) may be medically necessary for an individual whose functional level is 1 or |No |

|above. | |

|A flexible-keel foot (HCPCS code L5972) or multiaxial ankle/foot (HCPCS code L5978) | |

|may be medically necessary for an individual whose functional level is 2 or above. | |

|A flex foot system (HCPCS code L5980), energy-storing foot (HCPCS code L5976), | |

|multiaxial ankle/foot with dynamic response (HCPCS code L5979), a flex-walk system | |

|or equal (HCPCS code L5981), or shank system with vertical loading pylon (HCPCS | |

|L5987) may be medically necessary for an individual whose functional level is 3 or | |

|above. | |

|Is there documentation od the functional level of the patient? |Select from drop down: |

| |Yes or No |

|Knees | |

|Does the patient require a high activity knee control frame and have a functional |Select from drop down: |

|level of 4? |Yes or No |

|Does the patient require a fluid, pneumatic or electronic knees and has a |Select from drop down: |

|functional level of3 or above. |Yes or No |

|Does the patient require another type of knee system and has a functional level is 1|Select from drop down: |

|or above. |Yes or No |

|Is there documentation from the MD validating the functional level? |Select from drop down: |

| |Yes or No |

|Ankle | |

|Does the patient require an Axial rotation units (L5982 – L5986) ? |Select from drop down: |

| |Yes or No |

|Is the patient’s functional level 2 or above? |Select from drop down: |

| |Yes or No |

|Is there documentation of the patient’s functional level? |Select from drop down: |

| |Yes or No |

|Sockets | |

|Does the patient require a replacement socket? |Select from drop down: |

| |Yes or No |

|Has there been a change in the residual limb? |Select from drop down: |

| |Yes or No |

|Has there been a change in the functional need? |Select from drop down: |

| |Yes or No |

|Has there been irrepairable damage to the socket due to excessive weight of the | |

|patient? | |

|Is the damage related to a very active amputee? | |

|Is there documentation validating the patient’s functional level? | |

Mastectomy Bra/Breast Prosthesis/Garment

|Question |Reply or required information |

|Has the patient recently undergone a mastectomy? |Select from drop down: |

| |Yes |

| |No |

|Will the external prosthesis garment with mastectomy form be used postoperatively |Select from drop down: |

|prior to permanent prosthesis? |Yes or No |

|Will the garment be used as an alternative to mastectomy bra and breast prosthesis. |Select from drop down: |

| |Yes or No |

Protime Monitors

|Question |Reply or required information |

|Does the patient have a mechanical heart valve, chronic atrial fibrillation, or |Select from drop down box: |

|venous thromboembolism? |Yes or No |

|The patient has undergone anticoagulation management for at least 3 months?OR |Select from drop down box: |

| |Yes or No |

|The patient requires anticoagulation to similar levels as a mechanical heart valve |Select from drop down box: |

|(i.e. an INR greater than 3);? |Yes or No |

|Will the patient requires long term (> 1 year) anticoagulation? |Select from drop down box: |

| |Yes or No |

|Has the monitor and home testing has been prescribed by a physician? |Select from drop down box: |

| |Yes or No |

|Has the patient undergone an educational program on anticoagulation management and | Select from drop down box: |

|the use of the device prior to its use in the home |Yes or No |

|Will self-testing with the device be performed on a weekly basis.? |Select from drop down box: |

| |Yes or No |

Pulse Oximetry (Home)

|Question |Reply or required information |

|Used as adjunctive monitoring, is this a request for continuous home pulse oximetry?|Select from drop down: |

| |Yes or No |

|Does the patient have frequently fluctuating oxygen saturation levels that are | |

|clinically significant? (If yes, please describe) | |

|Are acute therapeutic interventions identified based on pulse oximeter measurements?|Select from drop down: |

| |Yes or No |

|Would the absence of readily available saturation measurements represent an |Select from drop down: |

|immediate health risk? |Yes or No |

|Does the patient have a trained caregiver to provide whatever care is needed to |Select from drop down: |

|reverse the low oxygen saturation level ordered by the physician? |Yes or No |

|Is continuous home pulse oximetry needed to validate continued need for home oxygen |Select from drop down: |

|therapy? |Yes or No |

|Is this a request for continuous overnight pulse oximetry in the home? |Select from drop down: |

| |Yes or No |

|Is the oximeter pre set and self sealed, such that that it cannot be adjusted by the|Select from drop down: |

|patient? |Yes or No |

|Does the device provide a printout that documents all of the following: |Select from drop down: |

|An adequate number of sampling hours |Yes or No |

|Percent of oxygen saturation | |

|Aggregate of the results | |

|Is the request for home pulse oximetry to be used as a sole diagnostic test for |Select from drop down: |

|obstructive sleep apnea (OSA)? |Yes |

| |No |

|Is the request for home pulse oximetry to be used in monitoring asthma patients? |Select from drop down: |

| |Yes |

| |No |

|Is the request for home pulse oximetry to be used for the routine monitoring of a |Select from drop down: |

|patient on long term home oxygen therapy, except when the patient’s physical |Yes |

|condition has changed, requiring an adjustment in the liter flow or their home |No |

|oxygen needs. | |

| | |

|REAUTHORIZATION—above questions and: |

|Has the patient had home pulse oximetry monitoring for one year? |Select from drop down: |

| |Yes |

| |No |

|For ongoing services has the physician provided all of the following history and | |

|physical, physician’s progress notes, and results of other laboratory studies such | |

|as blood gases, or pulmonary studies? | |

Respiratory Suction

|Question |Reply or required information |

|What type of suction machine is needed (portable, stationary, or gomco)? | |

|What respiratory condition does the patient have requiring a device to assist in the| |

|removal of excessive secretions (tracheostomy, laryngectomy)? | |

|What is the frequency of suctioning? | |

Seat Lift Mechanisms

|Question |Reply or required information |

|Does the patient have severe arthritis of the hip or knee, or have a severe |Select from drop down: |

|neuromuscular disease? |Yes or No |

|Is the seat lift part of the physician’s treatment plan? |Select from drop down: |

| |Yes or No |

|Has the seat lift been ordered to improve or retard deterioration of the patient’s |Select from drop down: |

|condition? |Yes or No |

|Is the patient completely incapable of standing up from any chair in their home? |Select from drop down: |

| |Yes or No |

|Once standing, is the patient capable of ambulation? |Select from drop down: |

| |Yes or No |

Transfer System (Hydraulic Lift, i.e. Hoyer Lift)

|Question |Reply or required information |

|What is the diagnosis for the lift mechanism? | |

|Would the patient be confined to bed without the lift? | |

|Is there a willing and available caregiver to assist in using the lift to transfer | |

|the patient out of bed to chair, wheelchair or commode? | |

|What type of lift is being requested (i.e. manual, hydraulic, multi-positional, | |

|overhead or ceiling, wall mounted or ceiling track)? | |

|Does the patient require supine positioning for transfers? | |

|Height | |

|Weight | |

Transcutaneous Electric Nerve Stimulation (TENS)

|Question |Reply or required information |

|Does the patient have acute post-operative pain? |Select from drop down |

| |Yes or No |

|Does the patient have chronic, intractable pain? |Select from drop down |

| |Yes or No |

|What other treatment modalities have been tried and failed? | |

|Is a TENS unit requested to treat any of the following conditions: |Select from drop down |

|Management of nausea and vomiting in pregnancy |Yes or No |

|Management of postoperative-induced or chemotherapy –induced nausea and vomiting | |

|Abdominal pain | |

|Pelvic pain | |

|Acute and chronic headache | |

|What is the expected use of duration? | |

|REAUTHORIZATION |

|Has the patient had a previous application of a TENS unit within the past 12 months?|Select from drop down |

| |Yes or No |

|Is the request for another TENS unit due to a new condition or injury/ |Select from drop down |

| |Yes or No |

|Has there been an extended interruption in treatment? |Select from drop down |

| |Yes or No |

|After 2 months of use, has the patient achieved relief by using the unit in the |Select from drop down |

|manner prescribed by the physician? |Yes or No |

Neuromuscular Electrical Stimulator (NMES)

|Question |Reply or required information |

|Does the patient have muscle atrophy due to lack of use? |Select from drop down: |

| |Yes or No |

|Is a NMES needed to enhance functional activity in a neurologically impaired patient|Select from drop down: |

|to activate paralyzed or weak muscles (either upper or lower extremity) in a precise|Yes or No |

|sequence format? | |

|Is the patient’s nerve supply to the muscle intact? |Select from drop down: |

| |Yes or No |

|Is the muscle atrophy caused by non-neurological reasons? |Select from drop down: |

| |Yes or No |

|Is the patient post hip-replacement surgery but has not yet started rehabilitative |Select from drop down: |

|training (usually within 1 month)? |Yes or No |

|Has the patient had a cast removed or splinting of a leg following major knee |Select from drop down: |

|surgery but has not yet started rehabilitative training (usually within 1 month)? |Yes or No |

|Does the patient have contractures resulting from severe burns where there is |Select from drop down: |

|reasonable expectation for improvement (for as long as significant improvement |Yes or No |

|continues to occur)? | |

|Will the device be used to treat a patient with muscle weakness due to central |Select from drop down: |

|nervous system, spinal, or peripheral nerve diseases/conditions affecting motor or |Yes or No |

|sensory pathways to and from the muscle(s) being stimulated (i.e. stroke, spinal | |

|cord injury or peripheral nerve injury)? | |

|Will the device be used to treat a patient who has a sprain or strain? |Select from drop down: |

| |Yes or No |

|Is the patient having pain associated with disuse atrophy? |Select from drop down: |

| |Yes or No |

|Will the device be used to treat scoliosis? |Select from drop down: |

| |Yes or No |

Ultrasound Osteogenesis Stimulators

|Question |Reply or required information |

|Does the patient have nonunion of a fracture that has been traditionally managed |Select from drop down: |

|with no signs of healing for a period of 3 months? |Yes |

| |No |

|Does the patient have a fresh, closed or grade I open, short oblique or short spiral|Select from drop down: |

|tibial diaphyseal fractures treated with closed reduction and cast immobilization in|Yes |

|skeletally mature patients with risk factors for poor or prolonged healing? |No |

|Does the patient have a fresh, closed or grade I open, short oblique or short spiral|Select from drop down: |

|tibial diaphyseal fractures treated with closed reduction and cast immobilization in|Yes |

|skeletally mature patients with no known risk factors for poor or prolonged healing?|No |

|Does the patient have fresh, closed fractures of the distal radius (Colles |Select from drop down: |

|fracture) treated with closed reduction and cast immobilization in skeletally mature|Yes |

|patients with risk factors for poor or prolonged healing, including articular |No |

|involvement, displacement at the time of injury, and > 10º of negative volar | |

|angulation? | |

|Does the patient have For fresh, closed fractures of the distal radius (Colles |Select from drop down: |

|fracture) treated with closed reduction and cast immobilization in skeletally mature|Yes or No |

|patients with no known risk factors for poor or prolonged healing? | |

|Is the device being used FDA approved? | Select from drop down: |

| |Yes or No |

|Is there documentation from the MD verifying non union of the fracture for a period|Select from drop down: |

|of 3 months? |Yes or No |

Speech Generating Device (SGD)

|Question |Reply or required information |

|Has the patient had an evaluation of their cognitive or communication abilities |Select from drop down: |

|completed by a speech-language pathologist? (Please fax) |Yes or No |

|What is the patient’s current communication impairment? (i.e. type, severity, | |

|language skills, cognitive ability, anticipated course of the impairment) | |

|What other natural modes of communication can the patient participate in? | |

|What are the treatment goals and treatment options? | |

|What device (and accessories) will meet the patient’s needs and why? | |

|Has a training schedule been identified for the device? | |

|Upon evaluation, is the patient cognitively and physically able to effectively use |Select from drop down: |

|the device and any accessories? |Yes or No |

|Upon evaluation, is this a request for an upgrade SGD because of the added benefit | |

|of an upgrade unit to the initially provided SGD? If yes, please specify | |

|What is the patient’s medical condition that involves severe expressive speech | |

|impairment? | |

|Can the patient’s speaking needs be met using natural communication methods? | |

|What other forms of treatment have been considered? | |

|Have those other forms of treatment been ruled out or tried and proven unsuccessful | |

|for the patient? If so, how? | |

|Will the patient’s speech impairment benefit from the device? |Select from drop down: |

| |Yes or No |

|Has the Speech Language Pathologist provided a written copy of the evaluation and |Select from drop down: |

|recommendations to the patient’s treating physician before ordering the device? |Yes or No |

|The Speech Language Pathologist is a health care professional not affiliated with |Select from drop down: |

|any suppliers of SGD? |Yes or No |

|Is software that enables a laptop computer, desktop computer or PDA to function as a|Select from drop down: |

|speech generating device needed? |Yes or No |

|Request the referral source to fax the type of device needed along with accessories | |

|needed and the reason for the accessory. | |

Traction Equipment and Weights

|Question |Reply or required information |

|Does the patient have an orthopedic impairment requiring traction? If yes, specify | |

|What kind of traction device is requested? (i.e. over the door, pelvic, lumbar)? | |

Trapeze

|Question |Reply or required information |

|What type of trapeze is requested? | |

|Does the patient need a trapeze in order to (specify): | |

|Sit up due to a respiratory condition | |

|Change body position for other medical reasons | |

|Get in or out of bed | |

|What is the patient’s weight? | |

Urinary collection and retention systems (Foley catheters, tubes, bags, etc.)

|Question |Reply or required information |

|Does the patient have permanent urinary incontinence? |Select from drop down: |

| |Yes |

| |No |

Ventilators

|Question |Reply or required information |

|Is the patient unable to maintain breathing without ventilator assistance? |Select from drop down: |

|Is the patient unable to maintain spontaneous respirations without the use of the |Yes or No |

|ventilator? | |

|Is the patient unable to maintain safe levels of arterial carbon dioxide and oxygen |Select from drop down: |

|without the use of the ventilator? |Yes or No |

|Is there an able and willing caregiver to assist with the ventilator? |Select from drop down: yes or no |

|Has the caregiver been instructed in the use of the ventilator? |Select from drop down: |

| |Yes or No |

|Will the ventilator be used continuously? |Select from drop down: |

| |Yes or No |

|Reauth: | |

|Is the patient unable to maintain spontaneous respirations without the use of the |Select from drop down: |

|ventilator? |Yes or No |

|Is the patient unable to maintain safe levels of arterial carbon dioxide and oxygen |Select from drop down: |

|without the use of the ventilator? |Yes or No |

|Has there been a change in the patient’s respiratory status? |Select from drop down: |

| |Yes or No |

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