Letter of Medical Necessity – Men’s LibertyTM by BioDerm
Patient Name:
Date of Birth:
Patient Address:
Medicare/ SSN #:
Phone:
Medical Information to be Completed by Physician
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2
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Patient experiences the following type of urinary incontinence (check all that apply):
 Urinary Incontinence (788.30)
 Post Void Dribbling (788.35)
 Urge Incontinence (788.31)
 Nocturnal Enuresis (788.36)
 Stress Incontinence (788.32)
 Continuous Leakage (788.37)
 Mixed Incontinence (788.33)
 Other Urinary Incontinence (788.39)
The patient’s urinary incontinence is a result of the following conditions
 Cerebral Palsy (343.9)
 Muscular Dystrophy (359.0)
 Spina Bifida (741.0)
 Quadriplegia (344.0)
 Multiple Sclerosis (340.0)
 Paraplegia (344.10)
 ALS (335.2)
 Prostate Cancer (185.0)
 Enlarged Prostate (233.4)
 Other ICD-9 Code: ___________
Additional health complication(s) relating to patient’s urinary dysfunction
 Urinary Tract Injury (599.0)
 Decubitis Ulcers (707.0)
 Penile Shaft Wound (878.0)
 Penile Ulcer (607.89)
 Urinary Tract Infection (98.0)
 Skin Irritation (782.1)
 Other ICD-9 Code: ___________)
I certify the medical necessity of BioDerm’s Men’s Liberty as the required therapy for this
patient. All other, less expensive means of collecting urine from this patient are not
successful for the patient to maintain health. I am ordering this product for the patient as a
reasonable and necessary treatment for his diagnosis.
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Plan of Care Information
Due to the patient’s permanent condition and because other methods will not provide
acceptable results, there is sufficent case evidence that Liberty has produced repeated
successful results with other patients. I prescribe the Men’s Liberty for life to be dispensed as
follows:
 Men’s Liberty
 Bed Bag
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2_
units/ month or 105 units/ 3 months (A4326)
units/ month 0r 6 units/ 3 months (A4357)
Physician Treating this Condition :___________________________
Office Phone: _________________ Fed ID # _____________ UPIN/ NPI # ______________
Physician Signature: ____________________________________Date: ________________
Return Complete Letter of Medical Necessity & Progress Note by fax to: 800-878-5405
Attention Doctors! We want to bother you even less than you want to hear from us!
Unfortunately, the Centers for Medicare and Medicaid Services requires us to have numbers 1, 2
and 3 above checked above AND a valid signature. STAMPS DON’T COUNT!
Example Cases – Progress Notes
Patient: Jim R. – Jamestown, NY
Age: 32
Diagnosis: Spinal Cord Injury
Progress Note states: Patient is not a candidate for condom catheters due to the repeated
daily removal of condom catheters for intermittent catheterization causing irritation/
inflamation fo the penis.“
Patient: Frank G. – Wilmington, DE
Age: 56
Diagnosis: CVA
Progress Note states: Patient is not a candidate for condom catheters due to frequent
wounds/ infections.“
Patient: William D. – Brandon, MS
Age: 88
Diagnosis: Geriatric Incontinence
Progress Note states: Patient is not a candidate for condom catheters due to small
anatomy.“
Patient: Harold W. – New Castle, PA Age: 78
Diagnosis: Prostate Cancer
Progress Note states: Patient is not a candidate for condom catheters because of retracted
anatomy.“
Patient: Jeffrey A. – Raleigh, NC
Age: 88
Diagnosis: ALS
Progress Note states: “Patient is not a candidate for condom catheters due to leakage/
persistnent moisture causing skin irritation.“
Patient: David L.- Chicago, IL
Age: 71
Diagnosis: Prostate Cancer
Progress Note states: Patient is not a candidate for condom catheters due to sensitivity to
materials and adhesive.“