Certificate of Medical Necessity Must Have
Most recent ABG pO2 and/or O2 Sat + Date of measurement
Is the patient mobile within the home? (Yes/No/Does not Apply)
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Highest oxygen flow rate ordered for this patient in liters per minute.
- If less than 1 LPM, enter an “X”.
- If > 4 LPM - note most recent ABG pO2 and/or O2 Sat while on oxygen + Date of measurement
If your patient has pO2 = 56-59 or O2 sat less than or equal to 89 then note whether the patient has any of the following (Yes or No)
Dependent edema secondary to congestive heart failure?
Cor pulmonale or Pulmonary HTN documented per EKG or Echo or Gated blood pool scan, Direct pulmonary artery pressure measurement?
Hematocrit > 56%?