Orthotics /
Fax or mail this
completed form / / For Pre-Service: Statewide Fax (877) 219-9448
For Medicare Advantage (BlueMedicare) HMO and PPO Plans: Fax (904) 301-1614
For Post-Service Claims:
Florida Blue
P.O. Box 1798
Jacksonville, FL 32231-0014
Section A
Physician Information/Requesting Provider
/Name:
/BCBSF No:
/National Provider Identifier (NPI):
Contact Name:
/Phone:
Facility Information/Location where services will be rendered /
Name:
/BCBSF No:
/National Provider Identifier (NPI):
Contact Name:
/Phone:
Member Information / Last Name: / First Name:Member/Contract Number (alpha and numeric): / Date of Birth:
Procedure Information / Procedure Code(s): / Procedure Description:
Diagnosis code(s): / Diagnosis Description:
Date of Service/Tentative Date:
SectionB
Medical Necessity: For detailed information on orthotics, including the criteria that meet the definition of medical necessity,visit the Florida Blue Medical Coverage Guideline website at Refer toMedical Coverage Guideline 09-L0000-03, Orthotics.
Section C
Checkany boxes in thearea that apply:
Yes / No / Is the request for any of the following orthotics?Check all that apply:
Appliances essential to effective use of artificial limbs or corrective braces
Braces for leg, arm, neck, back, shoulder
Describe:
Corsets for back or for use after special surgical procedures
Custom fabricated and designed foot orthosis
Harnesses essential to use of artificial limbs
Hernia devices
Orthopedic shoes when one or both are an integral part of a leg brace and are necessary for proper functioning of the brace
Replacement of an orthotic device when the need for replacement is documented by the attending physician and is due to change in patient's condition, loss, or irreparable damage or wear.
Explain:
Space shoes
Splints for extremities
Therapeutic shoes or sandals following surgical foot procedures
Therapeutic shoes (depth or custom molded) including inserts or modifications for the treatment of diabetic disease
Describe:
Shoe Quantity: Inserts Quantity:
Trusses
Yes / No / Is the request for custom molded and designed shoe inserts or supportive devices for the feet?
Yes / No / Were custom molded and designed shoe inserts prescribed to treat any of the following medical problems or deformities?
Check all that apply:
Strained or injured soft tissues
Bony prominences
Chronic or acute plantar fasciitis
Calcaneal spurs
Deformed bones and joints that impairs walking with a normal shoe
Rheumatoid nodules
Inflammatory conditions of the foot (i.e., sesamoiditis, submetatarsal bursitis, synovitis, tenosynovitis, synovial cyst, osteomyelitis, and plantar fascial fibromatosis, inflamed or chronic bursae
Dermatologic lesions secondary to deforming arthritis or biomechanical abnormality
A child with skeletally immature feet (Hallux valgus deformities; In-toe or out-toe gait; Musculoskeletal weakness (e.g., pronation, pes planus); Structural deformities (e.g., tarsal coalitions); Torsional conditions)
Other
Describe:
Yes / No / Is the request for therapeutic shoes, inserts or modifications for a member with diabetes?
Yes / No / Is the member under a comprehensive plan of care for the diabetic condition?
Yes / No / Does the member have one or more of the following conditions?
Check any that apply:
Previous amputation or the foot or part of the foot
Describe:
Foot deformity with a potential for ulceration
Describe:
Callus formation or a history of callus formation with peripheral neuropathy
History of previous foot ulceration
Poor pedal pulse or lower extremity circulation
Additional Comments:
I hereby certify that (i) I am the treating physician for above member, (ii) the information contained in and included with this Certificate of Medical Necessity is true, accurate and complete to the best of my knowledge and belief, (iii) the member’s medical records contain all appropriate documentation necessary to substantiate this information. I acknowledge that a determination made based upon this Certificate of Medical Necessity is not necessarily a guarantee of payment and that payment remains subject to application of the provisions of the member’s health benefit plan, including eligibility and plan benefits. Additionally, I further acknowledge and agree that Florida Blue may audit or review the underlying medical records at any time and that failure to comply with such request may be a basis for the denial of a claim associated with such services.Ordering Physician’s Signature: / Date:
Certificate of Medical Necessity:Orthotics1