Insurance

Certificate of Medical Necessity Durable Medical Equipment

OSTOMY BARRIER/SUPPORT U.S. Patent No. 4,888,006 & 5,135,520 Patient’s Name: _____________________________ Supplier: OPTIONS™ Ostomy Support/Barrier Inc. 92 Hayden Street Sayre, Pa 18840 HICN: __________________________________ TIN# 23-3000245 Tel: 800.736.6555 (Your Health Insurance Card Number) NPI# 1225137706

1. Diagnosis: ICD-9-CM Codes____V44.2 Ileostomy ____V44.3 Colostomy ____V44.6 Urostomy ____Other______

2. Length of Time Equipment Needed: ___ Code 99 – Permanent for patient’s lifetime. ____ Temporary ___ Number of Months

3. Place of Service: Patient’s Home – Code 12

4. CPT Code and NTE (additional narrative record field). It is imperative that all electronic claims provide the following NTE exactly as written or the claim will not be process properly and will be denied:

A. CPT - A4421 Ostomy Supply Miscellaneous

B. NTE - BarrierSupport protects peristomal skin,supports pouch,reduce leaks,extend weartime

PLEASE NOTE: The criteria for the NTE (additional narrative record field) is that it only contain 83 characters, therefore, it is imperative to use the above punctuation, spacing or non-spacing in order to accommodate the abbreviated reasons listed for medical necessity.

5. Reason for Medical Necessity:

A4421 Ostomy Supply Miscellaneous – OSTOMY BARRIER/SUPPORT Protects the peristomal skin integrity and prevents candidiasis. Supports the contents of the pouching system which maintains the adhesive seal; minimizing seal leaks thus extending the wear time of the pouching system. Saves nursing time and reduces total care costs.

The use of the Ostomy Barrier/Support is a medical necessity required for the patient’s '24–hour ostomy management program'. The Ostomy Barrier Support provides support to the pouching system seal by securing and supporting the weight of the pouch and its contents within the Ostomy Barrier/Support. Therefore, the contents do not undermine the adhesive seal; leaking the contents on the peristomal skin that eliminates necessitating the use of an additional pouching system. The other concern with the pouching system leakage relates to the integrity of the peristomal skin. If the pouching system leaks, the peristomal skin will become denuded further preventing the pouch from sealing, An additional benefit of the Ostomy Barrier/Support is the ability to lesson the amount of moisture on the pouch seal. The decrease of moisture will prevent the pouch seal adhesive from loosening and causing leakage and peristomal skin breakdown. Because of these reasons, the Ostomy Barrier/Support is a medical necessity for all ostomy patients and reduces total costs to the health care system.

7. Number of Supplies: Usage – 6 units every 90 days/24 per year . The Ostomy Barrier/Support is a medical necessity that is required for the patient’s '24-hour ostomy management program'.

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