AEROFLOW HEALTHCARE
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PATIENT #:
CERTIFICATE OF MEDICAL NECESSITY FOR HINGED KNEE BRACE
HIC#:
PATIENTS NAME:
STREET ADDRESS:
PATIENT TELEPHONE:
PATIENT DOB:
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ORDERING PRACTITIONER:
ADDRESS:
TELEPHONE:
PRACTITIONER NPI:
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What is the patient’s Diagnosis Code?
714.0 - Rheumatoid Arthritis
717.0 - Meniscal Cartilage Derangement
717.81 - Knee Ligamentous Disruption
733.49 - Asceptic Necrosis of Tibia or Fibula
821.20 - Fracture of Femur-Lower End
823.00 - Fracture of Tibia or Fibula-Upper
844.0 - Sprain & Strain of Knee
715.16 - Osteoarthritis
717.7 - Chrondromalacia of patella
727.65 - Rupture of quadriceps tendon
733.16 - Pathologic fracture of Tibia/fibula
733.93 - Stress fracture of Tibia/fibula
836.0 - Dislocation of Knee
Other:______________________________
Please Select the Product Prescribed and the knee(s) with the medical need:
L1832 – Hinged Knee Brace – Rigid support orthosis with adjustable joints
Right
Left
Both
L1820 – Sleeve Knee Brace – Elastic and condylar pads and joints
Right
Left
Both
Describe why this patient requires the product prescribed above:
To reduce pain by restricting mobility of the knee joint.
To facilitate health and reduce pain following an injury to knee or related soft tissues.
To facilitate health and reduce pain following a procedure on the knee or related soft tissue.
To otherwise support weak upper or lower leg muscles/joints and/or a deformed knee joint.
Other: ______________________________________________________________
***Medical justification must be documented in the patient’s medical record***
BY SIGNING BELOW, I AUTHORIZE the use of this document as a legal prescription and I certify that the above prescribed
equipment is medically necessary and reasonable, and is consistent with the current standards of medical practice and
treatment of this patient’s condition. I will maintain an original, signed copy of this physician order in my medical records and
make it available to Medicare, their authorized agents, or other insurer, if required.
Order Date:_______________________
Length of Need: _______ months (99 mos. = lifetime need)
Signature:___________________________________________
(NO SIGNATURE STAMPS)
Signature Date:_________________