Currentblue cross blue shield - minnesotaPolicy N/A

Durable Medical Equipment (DME) certification form

This document is a DME certification/recertification form governing physician attestation and supplier requests for durable medical equipment, oxygen, IPPB, glucometers, and related devices for Blue Cross Blue Shield - Minnesota members.

Policy Summary

Payerblue cross blue shield - minnesota

PolicyDurable Medical Equipment (DME) certification form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescribing physician must complete, hand-sign, and date the certification form and provide required clinical details (including HCPCS codes, rental period, and PaO2/oximetry results when applicable).

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POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12max DME certification (months)

6oxygen/IPPB certification (months)

Requiredphysician signature

PaO2/oximetryoxygen documentation

Coverage Criteria and Clinical Requirements

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Form completion and equipment-specific clinical data

Coverage is supported when the prescribing physician completes the form providing required clinical details and attests equipment is reasonable and necessary.

General DME certification requirements: Physician must complete patient information, diagnosis, prognosis, estimated number of months equipment needed (do NOT put 'INDEFINITE'), mobility status, supplier information, requested HCPCS code(s), supplier provider number, and rental period with certification length not to exceed 12 months.

See form fields in chunk 1 and certification period in chunk 1

Oxygen-specific requirements: Provider must retain and provide PaO2 or oximetry lab results (blood gas study) in the patient file, indicate where the test was performed, document whether it was taken at rest/with activity/sleep, record whether patient was on room air or oxygen, specify type(s) of oxygen unit prescribed, hours per day (portable and non-portable), flow rate in L/min, delivery method, and list prior treatments tried without success.PaO2/oximetry lab results required (values retained in file)

See chunks 4 and 23

IPPB-specific requirements: Provide current pulmonary function study results (forced vital capacity before and after aerosols as applicable), state intended frequency/usage of IPPB and treatment goals.

See chunk 5

Glucometer-specific requirements: Document whether patient is insulin-dependent, average daily insulin dose, insulin type, number of daily injections, presence of widely fluctuating pre‑meal blood sugars or frequent insulin reactions, whether frequent self‑monitoring is necessary, vision impairment requiring a special monitor, and capability to be trained to use a home glucose monitor.

See chunk 6

The form requires the prescribing physician to certify that the equipment is "reasonable and necessary" and is not prescribed as convenience equipment. This attestation is a mandatory element of the certification and supports adjudication of the DME claim.

The form contains a clear notice that it "must be completed, signed and dated by the prescribing physician to accurately adjudicate the DME Claim." Incomplete, unsigned, or uncertified forms may jeopardize adjudication or lead to denial of the request.

Requested Codes and Clinical Data for Coding

Requested HCPCS CodesHCPCS

Requested HCPCS code(s)

Place on form — supplier must list requested HCPCS code(s)

PaO2 or oximetry — lab results required

RequirementProvide blood gas study (PaO2) or oximetry lab results and retain them in provider files.

Test conditionsDocument patient condition during test (during activities/exercise, at rest, while sleeping) and whether patient was on room air or oxygen at time of study.

Oxygen parametersRecord hours per day on oxygen (portable and non-portable), flow rate (L/min), and delivery method (nasal cannula, mask).

Prior treatmentsList treatments tried without success prior to oxygen therapy (bronchodilators, medications with names/doses, physical therapy including percussors and breathing exercises, other treatments).

Supplier and Prescriber Actions Required

Documentation Required

HCPCS and Certification Period

Supplier must record the requested HCPCS code(s) and specify the rental/certification period. Certification length cannot exceed 12 months; enter First Day and Last Day (MM-DD-YYYY).

Requested HCPCS code(s) must be listed on the form (Item 11).
Enter Rental Period / Certification Dates (First Day and Last Day).
Certification length CANNOT exceed 12 months.

Documentation Required

Prior Treatments for Oxygen Therapy

List prior treatments that were tried without success before initiating oxygen therapy. Include dates (begin and end) and specifics for bronchodilators, medications (name and dosage), physical therapy (percussors, breathing exercises), and any other treatments.

Document bronchodilators tried (YES/NO) with start and end dates.
Document medication name(s), dosage, and dates.
Document physical therapy interventions (percussors, breathing exercises) with dates.
Document any other prior treatments with dates.

Documentation Required

Required Documentation on Form

Complete all required patient and clinical documentation on the form. Do not use 'INDEFINITE' for estimated duration—provide a specific number of months. Record patient ID, date last seen, diagnosis, prognosis, estimated months equipment needed, and mobility details (bed-, room-, wheelchair-confined; ambulatory status; disorientation). Include oxygen test results (PaO2 or oximetry), test date and setting, condition during test (rest, exercise, sleep), whether on room air or oxygen, prescribed unit type, hours per day, flow rate, and delivery method.

Patient identification: name and subscriber number.
Date patient last seen by doctor and diagnosis.
Prognosis: Good/Fair/Poor.
Estimated number of months equipment needed (do NOT put 'INDEFINITE').
Mobility details: bed/room/wheelchair confined, ambulatory assistance, disorientation.
Oxygen testing: report date, PaO2 or oximetry level, test location, condition during test, room air vs oxygen.
Prescribed oxygen details: unit type (portable/stationary/concentrator/liquid/gaseous), hours per day (portable and non-portable), flow rate (L/min), delivery method (nasal cannula, mask), and exercise therapy specifics if applicable.

Prior Authorization

Physician Signature Requirement

The prescribing physician must complete, sign (handwritten signature required; stamped signature not acceptable), and date the form certifying active treatment and medical necessity. The physician's name, address, provider number, specialty, and office telephone must be included. Misrepresentation may constitute fraud.

Attending physician's handwritten signature and date (stamped signature NOT acceptable).
Physician's name, address, provider number, specialty, and phone number.
Signed certification that the physician is actively treating the patient and the equipment is reasonable and necessary.

Definitions and Equipment Categories

List of DME categories

BedsAlternating P.P. & Pump; Bed, Electric; Bed, Semi-electric; Bed, Standard; Bed, Variable Height.

Mobility aidsCane or Quad Cane; Walker (with wheels option); Wheelchair (standard, electric, detachable arms, leg rests, special).

Bathroom & transfer aidsCommode, Bedside; Lift, Patient; Rails, Bedside; Trapeze Bar.

Respiratory equipmentNebulizer (hand-held, ultrasonic); Percussor; Suction Machine; Oxygen (portable, stationary, concentrator, liquid, gaseous); IPPB.

Other DMESitz Bath; Traction Equipment; Other (free-text description field on form).

PaO2 or oximetry results retained in provider files to substantiate need for oxygen therapy

Documentation retentionRetain PaO2 or oximetry lab results in provider files to substantiate need for oxygen therapy.

Test contextRecord whether test was during activities (exercise), at rest, or while sleeping, and whether patient was on room air or oxygen at time of study.

Functional and Training Criteria for Medical Necessity

Functional/training criteria

Functional and training information must be provided as indicated on the form for the specific equipment selected.

Electric bed usability: For electric beds, indicate whether the patient is able to operate the controls and make adjustments, and whether the patient's condition requires frequent changes in body position not feasible in an ordinary bed.

See questions 13 and 14 in chunk 3

Mobility status: Document whether the patient is bed confined (and percent of time), room confined, wheelchair confined, ambulatory (with details: assistance not required, assisted by walker or cane, assisted by person), and whether the patient is disoriented.

See mobility items in chunk 1

Percussor training and home support: Indicate whether the patient has been trained by a therapist or physician to use a powered percussor and whether there is someone at home who can administer manual therapy.

See question 16 in chunk 3

Rental and Purchase Rules

Equipment	Rental rule / certification period
General DME rentals	Certification length cannot exceed 12 months; form requires entering first and last day of the certification period (rental period).
Required supplier information and HCPCS	Supplier name, provider number, and requested HCPCS code(s) must be recorded on the form for adjudication; rental period entered on form.

Equipment	Rental rule / certification period
Oxygen / IPPB	Certification length for oxygen/IPPB section cannot exceed 6 months.
IPPB-specific documentation	Provider must document current pulmonary function study results, IPPB frequency of use, and intended goals of IPPB use on the form.

Documentation Retention and Required Details

Documentation Required

Document PaO2/oximetry results and supplier/HCPCS details on form

Retain and place current PaO2 or oximetry blood gas study results on the certification form (report date, PaO2 level or oximetry level) and indicate where the test was performed; also list requested HCPCS codes, supplier name and provider number, and the rental/certification period on the form.

Include PaO2 or oximetry results and report date; note condition during test (at rest, during activity, while sleeping) and whether on room air or oxygen.
Document where test was done (home, doctor's office, nursing home, independent lab, hospital, ASC).
List requested HCPCS code(s), supplier name/address/phone, and supplier provider number, plus certification First Day and Last Day.

Documentation Required

Handwritten physician signature required (no stamps)

Attending physician's handwritten signature and date are mandatory on the certification form; stamped signatures are explicitly not acceptable.

Handwritten signature required in the Attending Physician signature block.
Stamped signature is not acceptable and will not meet the form requirement.

Policy Summary

Payerblue cross blue shield - minnesota

PolicyDurable Medical Equipment (DME) certification form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

OpenPayer

Durable Medical Equipment (DME) certification form

Coverage Criteria and Clinical Requirements

Requested Codes and Clinical Data for Coding

Supplier and Prescriber Actions Required

Background and Purpose

Definitions and Equipment Categories

Functional and Training Criteria for Medical Necessity

Rental and Purchase Rules

Documentation Retention and Required Details

Exclusions and Not Covered Items