"Certificate of Medical Necessity Form - Custom Breast Prosthesis L8035"

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CERTIFICATE OF MEDICAL NECESSITY
Type of Service: CUSTOM BREAST PROSTHESIS L8035
Patient Name:___________________________________________________________ DOB:________________
Address:__________________________________ City:____________________ State:_________ Zip:_________
Phone:_______________________________ ID#:________________________Group#:_____________________
Diagnosis:
174.9
Malignant neoplasm of breast: (Left,
Right,
Bilateral)
V45.71 Acquired absence of breast: (Left,
Right,
Bilateral)
Statement of Medical Necessity (check all that apply)
_____ Lymphedema
_____ Lymph Node Removal
_____ Tried & failed surgical breast reconstruction
_____ Not a candidate for surgical breast reconstruction
_____ Excessive Keloid formation
_____ Changes in chest wall
_____ Asymmetrical chest wall as a result of LEFT mastectomy
_____ Asymmetrical chest wall as a result of a RIGHT mastectomy
_____ Asymmetrical chest wall as a result of a BILATERAL mastectomy
_____ Bone loss/Osteoporosis
_____ Back, neck and/or shoulder strain warranting lightweight prosthesis
_____ Patient prefers non-surgical breast reconstruction over invasive surgery
_____ Failed alternative, off-the-shelf breast form
Most recent hospital stay: ______________________________________
Has the patient previously been hospitalized for this condition? YES _____ NO _____
Date of patient’s first symptom: __________________________________
Date patient was last examined: _________________________________
Date of patient’s surgery: ______________________________________
Physician’s Order: Custom Breast Prosthesis/External Breast Restoration Fitting
For Absence of Breast
Left _____ Right _____ Bilateral _____
Notes:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Physician’s Name: _____________________________ Phone: ____________________UPIN:________________
Address: _____________________________________City:____________________State: _______ Zip:________
I certify that this patient is under my care and that the above described products/services are medically necessary.
Physician’s Signature:____________________________________________________Date__________________
According to the Women’s Health and Cancer Rights Act of 1998, insurance coverage must include all
stages of reconstruction of the diseased breast, procedures to restore and achieve symmetry on the
opposite breast and the cost of prostheses and complications of mastectomy, including lymphedema.
CERTIFICATE OF MEDICAL NECESSITY
Type of Service: CUSTOM BREAST PROSTHESIS L8035
Patient Name:___________________________________________________________ DOB:________________
Address:__________________________________ City:____________________ State:_________ Zip:_________
Phone:_______________________________ ID#:________________________Group#:_____________________
Diagnosis:
174.9
Malignant neoplasm of breast: (Left,
Right,
Bilateral)
V45.71 Acquired absence of breast: (Left,
Right,
Bilateral)
Statement of Medical Necessity (check all that apply)
_____ Lymphedema
_____ Lymph Node Removal
_____ Tried & failed surgical breast reconstruction
_____ Not a candidate for surgical breast reconstruction
_____ Excessive Keloid formation
_____ Changes in chest wall
_____ Asymmetrical chest wall as a result of LEFT mastectomy
_____ Asymmetrical chest wall as a result of a RIGHT mastectomy
_____ Asymmetrical chest wall as a result of a BILATERAL mastectomy
_____ Bone loss/Osteoporosis
_____ Back, neck and/or shoulder strain warranting lightweight prosthesis
_____ Patient prefers non-surgical breast reconstruction over invasive surgery
_____ Failed alternative, off-the-shelf breast form
Most recent hospital stay: ______________________________________
Has the patient previously been hospitalized for this condition? YES _____ NO _____
Date of patient’s first symptom: __________________________________
Date patient was last examined: _________________________________
Date of patient’s surgery: ______________________________________
Physician’s Order: Custom Breast Prosthesis/External Breast Restoration Fitting
For Absence of Breast
Left _____ Right _____ Bilateral _____
Notes:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Physician’s Name: _____________________________ Phone: ____________________UPIN:________________
Address: _____________________________________City:____________________State: _______ Zip:________
I certify that this patient is under my care and that the above described products/services are medically necessary.
Physician’s Signature:____________________________________________________Date__________________
According to the Women’s Health and Cancer Rights Act of 1998, insurance coverage must include all
stages of reconstruction of the diseased breast, procedures to restore and achieve symmetry on the
opposite breast and the cost of prostheses and complications of mastectomy, including lymphedema.