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Certificate of Medical Necessity — Home Oxygen and Oxygen Equipment: 5-Year RUL Replacement and Renewal
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This document governs requests for replacement of home oxygen and oxygen equipment at or after the 5-year reasonable useful lifetime (RUL) and renewals after replacement for Alaska Medicaid members; it specifies required attestations, prescriber certification, and form completion that support service authorization under Alaska regulations.
No material clinical or coverage changes in this revision.
Coverage criteria for replacement and renewal
Coverage criteria for replacement or renewal
Covered when ALL of the following are met
Purpose must be indicated on the form.
Complete only when Purpose of Submission is 5-Year RUL Replacement; attestation items are left blank for Renewal submissions.
Certification is based on clinical evaluation and required checkboxes must be completed.
If any required element is missing, a separate prescription may be required and omission may lead to denial.
Equipment types and required fields are enumerated on the form.
For Renewal submissions do not complete the supplier attestation items on the form. The supplier attestation section is required only when the Purpose of Submission is 5-Year RUL Replacement; for Renewals the attestation fields should be left blank.
If the prescriber does not certify current medical need, expected duration (indefinite or specified months), and that the ordered equipment is medically necessary by completing Section C and providing a prescriber signature and date, the request will not satisfy the medical necessity certification requirement. When all required prescription elements listed on the form (including estimated length of need and requested start date) are not present the form may not serve as the prescription order and additional documentation or a separate prescription may be required.
Diagnosis, RUL and exam timing
| ICD-10 codes (up to 3) | Diagnosis codes and descriptions supporting medical necessity (entered by prescriber on form) |
What providers must do
Submit completed CMN and supplier page with prior authorization
Submit the completed Home Oxygen and Oxygen Equipment form with the service authorization request to Durable Medical Equipment Service Authorization Requests using the listed fax, DSM, or mail options; include the completed supplier page with the authorization.
- Fax (toll-free): (888) 772-3632
- Fax (local): (907) 644-8131
- DSM or Mail: DmeSA@hms.fa.directak.net; Service Authorization P.O. Box 240808 Anchorage, AK 99524-0808
Supplier must attest RUL ≥ 60 months and member elected replacement
For 5‑Year RUL Replacement submissions the supplier must attest, on the supplier page, that the original initial date of service was 60 or more months prior and that the member elected replacement; the supplier representative signature and date are required.
- Complete the three attestation items based on supplier records when Purpose of Submission = 5‑Year RUL Replacement.
- Leave attestation items blank for Renewal submissions.
Required CMN elements to include with service authorization
Include the completed Certificate of Medical Necessity form with member demographics, diagnosis codes (up to three), equipment order (item, LPM, frequency, quantity), estimated length of need, requested start date, and prescriber signature and date when submitting the service authorization.
- Member name and date of birth (Section A)
- Diagnosis and ICD code(s) (Section B) — up to 3 diagnoses
- Equipment item(s), LPM, frequency, and quantity (Section D)
- Estimated length of need and requested start date (Section B)
- Prescriber signature and date
Incomplete form elements can cause denial of authorization
If required form elements are missing (for example, prescriber signature, required form fields, or supplier attestation for RUL Replacement), the completed form will not serve as the prescription and the service authorization may be denied.
- Missing prescriber signature or date prevents the form from serving as the prescription.
- Missing supplier attestation on RUL Replacement submissions may lead to denial.
- If elements are incomplete a separate prescription may be required and authorization can be delayed or denied.
Clinical background
Home oxygen and oxygen equipment are prescribed for members with a documented need for supplemental oxygen. The Certificate of Medical Necessity form documents the prescriber's clinical certification that oxygen is medically necessary, the expected duration of need, and the specific equipment ordered; when the form contains all elements required under 7 AAC 120.200(t) it may serve as the prescription order.
Key definitions
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