CurrentHighmark Blueshield NenyPolicy N/A

Certificate of Medical Necessity for Durable Medical Equipment

This supplier/prescriber form and instruction set is required by Highmark Blue Shield to document claims information and physician certification when requesting payment for durable medical equipment, prosthetic and orthotic devices; it affects suppliers, prescribing physicians, and claims processors submitting DME-related claims.

Policy Summary

PayerHighmark Blueshield Neny

PolicyCertificate of Medical Necessity for Durable Medical Equipment

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSupplier must complete required form fields and the prescribing physician must sign and date the form before equipment may be considered for payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

form fieldsform fields

equipment itemsequipment items

signaturesignature required

Coverage Criteria — Certificate of Medical Necessity

Administrative medical necessity documentation

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Form completion requirements: All required patient identification fields, diagnosis, prescription date, duration needed (months), prognosis, rental period (if applicable), and equipment-specific yes/no questions must be completed on the supplier-completed Insurance Claim Form.

The prescribing physician must sign and date the form before equipment may be considered for payment; if equipment is not used in the patient’s home, include the facility name and address.

The Certificate of Medical Necessity functions as an administrative form to document clinical details that support payment for durable medical equipment (DME). It does not set clinical exclusion rules on its face; rather, it records item-specific clinical information (e.g., bed confinement, need for special positioning, susceptibility to decubitus ulcers, ambulation impairment) that payors and adjudicators use to determine medical necessity. The form itself lists no explicit clinical exclusions.

This supplier/prescriber form does not define conditions that are categorically not medically necessary. Instead, it documents required elements that must be provided to support a medical necessity determination. Note that incomplete, unsigned, or improperly completed forms — for example missing patient identification, diagnosis, prescription date, duration, prognosis, equipment selection, or the equipment-specific yes/no responses — may result in denial of payment.

Provider Actions, Required Documentation, and Risks

Documentation Required

Physician Signature Required

This form must be signed and dated by the prescribing physician before the equipment may be considered for payment. The signature certifies that the information and judgment reflected on the Certificate of Medical Necessity represent the physician's assessment of the patient's need.

Physician's printed name, phone number, and address must be provided.
Include facility name and address if equipment will be used outside the patient's home.
Physician's signature and date are required on the form.

Denial Risk

Incomplete Form Risks Denial

Claims may be denied if required Certificate of Medical Necessity fields are missing or incomplete. Missing patient identifiers, diagnosis, prescription date, duration, prognosis, physician signature, or supplier-completed Insurance Claim Form fields can result in claim denial or delayed payment.

Required fields: patient name, agreement number, diagnosis, date equipment prescribed, duration (months), prognosis.
Supplier must complete Insurance Claim Form fields (patient name, agreement number, diagnosis, prescription date, duration, etc.).
Omitted or illegible physician signature/date risks denial.

Documentation Required

Required Documentation and Physician Certification

The supplier and prescribing physician must ensure all required documentation and physician certification are completed. The supplier must fill the insurance claim fields and the physician must certify medical necessity by signing and dating the Certificate of Medical Necessity.

Supplier responsibilities: complete Insurance Claim Form fields and supply any model/feature specifics and diagnosis supporting medical necessity.
Physician responsibilities: complete prescription details (equipment prescribed, duration, prognosis) and sign/date the form to certify medical necessity.
If multiple items (e.g., walker plus side rails) are prescribed, provide explanations why each item is medically necessary.

Step Therapy

Step therapy is not specified on this Certificate of Medical Necessity form. Providers should follow any separate payer step-therapy or conservative therapy requirements that may apply under Highmark Blue Shield policies.

Check applicable Highmark Blue Shield coverage guidelines for step-therapy or prior conservative treatment requirements before submission.
Absence of step-therapy detail on this form does not waive any policy-level step-therapy requirements.

Form Item Questions for Medical Necessity

Form item questions

Item-specific questions included on the form to justify medical necessity:

Hospital Bed questions: Is the patient bed confined? Does the patient’s condition require positioning of the body or attachments which would not be feasible with an ordinary bed? Does the patient’s condition require frequent and/or immediate changes in body position?

Answers captured via form fields A/B/C as YES/NO.

Electric Hospital Bed / Side Rail / Trapeze questions: Can the patient operate the controls himself? Is the patient disoriented at any time? Is there a need for the patient to sit up due to respiratory conditions or similar?

Answered under corresponding lettered fields (D, E, G).

Alternating Pressure Pad / Skin risk questions: Is the patient highly susceptible to decubitus ulcers? Are you supervising the use of the pressure pad?

Answered under fields I/J and supports need for alternating pressure pads or special mattresses.

Mobility equipment questions: Does the patient’s condition impair ambulation? Is the patient’s condition such that the alternative would be bed or chair confinement? Is the walker used for therapy?

Answered for wheelchair, walker, cane/quad cane usage (fields K, L, M).

Commode / Floor confinement question: Is the patient confined to floor without bathroom facilities?

Answered under field N; if ambulatory equipment is used with non-ambulatory equipment, an explanation of medical necessity for both is required.

Supplier and Physician Documentation Requirements

Billing Rule

Supplier completes form; physician signature required for payment

The supplier must complete all form fields and the prescribing physician must sign and date the form before payment will be considered; the form must include the selected equipment and the specific YES/NO clinical responses required for each equipment type.

Supplier completes equipment selection and answers to corresponding questions (e.g., bed confined, need for positioning, ambulation impairment, susceptibility to decubitus ulcers).
Physician signature certifies the judgment of the patient's need and must include printed name, phone number, and address.

Rental and Purchase Rules

Item	Rental / Purchase rule
Hospital Bed	Form requests a rental period: 'This prescription applies to rental period from ___ to ___' indicating rental periods are documented; no further rental vs purchase rules stated.
Electric Hospital Bed	Form requests a rental period to be documented; no additional rental or purchase rules are specified on the form.
Side Rails	Rental period field present on form; the document does not state specific purchase vs rental criteria.
Commode	Form includes fields for documenting the rental period but provides no further rental/purchase guidance.
Trapeze Bar	Rental period is requested on the form; no other rental/purchase rules are included.
Alternating Pressure Pad / Mattress	Form includes rental period fields but does not specify rental-versus-purchase rules for this equipment.
Wheelchair	The prescription form captures a rental period but does not define rental vs purchase rules for wheelchairs.
Walker / Cane / Quad Cane	Rental period can be documented on the form; no purchase vs rental policy language is provided.
Other equipment (free-text)	Form allows listing other equipment and requests a rental period, but contains no further rental or purchase rules.

Definitions and Interpretations

Bed confined — form assessment

Bed confined (form question)Question A: 'Is the patient bed confined?' — used to assess whether patient is confined to bed

Related mobility assessmentQuestion K/L/M ask whether condition would result in bed or chair confinement or impair ambulation — supports bed confinement determination

Facility/home contextQuestion F and N assess room or floor confinement and bathroom access, informing confinement status

Background

The form collects focused clinical context tied to common DME categories to justify why specialized equipment is required instead of ordinary household items. Examples of information captured include whether the patient is bed confined, whether special positioning or attachments are required that an ordinary bed cannot provide, whether frequent or immediate changes in body position are needed, susceptibility to decubitus (pressure) ulcers, and whether the patient’s condition impairs ambulation. These item-level questions are used to substantiate medical necessity for specific equipment types (hospital bed, alternating pressure pad, wheelchair, walker, cane, etc.).