CERTIFICATE OF MEDICAL NECESSITY

STATEMENT OF CERTIFYING PHYSICIAN (M.D. or D.O.)

For Therapeutic Footwear

Patient   _______________________________________________________        Date of Birth  _________________________

                                                                                                                                                           HIC # ____________________________

I certify that all of the following statements are true:   

1)       I am treating this patient under a comprehensive plan of care for his/her diabetes and the patient needs    

       diabetic shoes; and

2)       This patient has diabetes mellitus:      ICD-9 Code(s):  __________    (250.00-250.91); and                                                                               

3)       I have notated in the patient’s medical records that they have diabetes; and

       4)   This patient has one or more of the following conditions (as documented in patient’s medical records).

             Check all that apply:

Previous amputation of the other foot, or part of either foot, or                                    ICD-9 Code(s):  __________

History of previous foot ulceration of either foot, or                                                       ICD-9 Code(s):  __________

History of pre-ulcerative callus of either foot, or                                                              ICD-9 Code(s):  __________

Peripheral neuropathy and evidence of callus formation of either foot, or                   ICD-9 Code(s):  __________

Foot deformity of either foot  (bunion, hammertoes, ____________________) or  ICD-9 Code(s):  __________

Poor circulation (i.e., small or large vessel arterial insufficiency) in either foot            ICD-9 Code(s):  __________

Physician Signature:            _________________________________________________    Date:      ___________________________

Physician Name (Print) _________________________________________________   NPI #:           ___________________________

Physician Address:              ____________________________________________________________________________________

 ____________________________________________________________________________________

Physician Phone ______________________________ 

Physician Fax      ______________________________

Note  Signature and date stamps not acceptable

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This is a request for the M.D. or D.O. who has the primary responsibility of treating the patient’s systemic diabetes, to complete the Certificate of Medical Necessity above for the patient listed so that we (the DMEPOS Supplier) may provide them with therapeutic shoes and inserts.  In order to qualify for Medicare reimbursement, your certification that they meet the conditions listed below is required.  Per Medicare guidelines (excerpt below from Cigna Government Services), in the event of an audit for this particular patient’s claim for therapeutic shoes and inserts:

It is important to note that even though you may complete and sign a form attesting that all of the coverage requirements have been met, there also must be documentation in your records to indicate that you are managing the patient’s diabetes and that one of the conditions listed below is present.  If requested by the supplier, you must provide copies of those records.

Such an audit from Medicare would typically include a request from us that you provide this documentation, in which case we would also send you a copy of Medicare’s request.  If you would not be able to meet such a request, please contact us prior to completing this form.  We greatly appreciate your assistance in providing for this patient.

QUESTIONS CALL:  512-374-0818                 FOOT PAIN RELIEF STORE LLC             FAX BACK TO:  512-374-0810