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Date Printed: January 28, 2015: 05:11 PM

Certificates of Medical Necessity

To expedite the medical review process for certain requests, Florida Blue provides Certificate of Medical Necessity (CMN) forms to our Providers. Each CMN is associated with one of Florida Blue’s Medical Coverage Guidelines (MCG). CMNs offer Providers a way to attest to information within a member’s medical documentation, rather than requiring the Provider to send that documentation to Florida Blue.

A list of available CMNs and their associated MCGs appears below.

Additionally, a blue document symbol will appear in the top left corner of each associated MCG following the 9-digit MCG policy number. This indicates an MCG has an associated CMN. Information about each CMN is located in the Position Statement section in each MCG.

Pre-Service Medical Review Fax Cover Sheet

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Instructions

1. Click on the appropriate CMN link below to open the CMN form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form along with your request as directed on the CMN.

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Ambulance

CMN MCG Ambulance Services

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Durable Medical Equipment

CMN MCG Blood Glucose Monitors and Supplies

CMN MCG Continuous Passive Motion Device

CMN MCG Oxygen

CMN MCG Positive Airway Pressure Devices

CMN MCG Wheelchairs and Wheelchair Components

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Medicine

CMN MCG Chelation Therapy

CMN Chiropractic Services (Medicare)

CMN MCG Home Prothrombin Time Monitoring

CMN MCG Nerve Conduction Studies, F Wave Studies, H Reflex Studies

CMN MCG Physical Therapy (PT) and Occupational Therapy (OT)

CMN MCG Sleep Testing

CMN MCG Speech Therapy

CMN MCG Speech Therapy in the Home

CMN MCG Wireless Capsule Endoscopy

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Other

CMN MCG Hyperalimentation

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Pathology and Laboratory

CMN MCG Allergy Testing

CMN MCG Genetic Testing for Hereditary Breast or Ovarian Cancer

CMN MCG Helicobacter Pylori (H. Pylori) Testing

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Pharmacy

CMN MCG Adalimumab (Humira®)

CMN MCG Etanercept (Enbrel®)

CMN MCG Gonadotropin Releasing Hormone Analogs and Antagonists

CMN MCG Growth Hormone Therapy

CMN MCG Infliximab (Remicade®)

CMN MCG Omalizumab (Xolair®)

CMN MCG Palivizumab (Synagis®)

CMN MCG Rituximab (Rituxan®)

CMN MCG Rituximab (Rituxan®) Medicare

CMN MCG Teriparatide (Forteo®)

CMN MCG Ustekinumab (Stelara™)

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Radiology

CMN MCG Intensity-Modulated Radiation Therapy (IMRT)

CMN MCG Ultrasounds in Maternity Care

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Surgery

CMN MCG Acne Treatments

CMN MCG Allogeneic Bone Marrow and Stem Cell Transplant

CMN MCG Bariatric Surgery

CMN MCG Carotid Angioplasty and Stenting (CAS)

CMN MCG Cochlear Implants

CMN MCG Blepharoplasty/Brow Surgical Procedures

CMN MCG Epidural Injections

CMN MCG Facet Joint Injections

CMN MCG Heart and Lung Transplant

CMN MCG Heart Transplant

CMN MCG Infertility

CMN MCG Keratoplasty

CMN MCG Kidney Transplantation

CMN MCG Liver Transplant

CMN MCG Lung and Lobar Lung Transplant

CMN MCG Mastectomy for Gynecomastia

CMN MCG Nerve Block Injections

CMN MCG Neurolysis

CMN MCG Pancreas Transplantation

CMN MCG Pancreatic Islet Cell Transplantation

CMN MCG Reduction Mammoplasty

CMN MCG Sacroiliac Joint Injections

CMN MCG Septoplasty

CMN MCG Small Bowel Transplant

CMN MCG Small Bowel, Liver and Multivisceral Transplant

CMN MCG Treatments for Varicose Veins

CMN MCG Treatments for Varicose Veins - Medicare

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Date Printed: January 28, 2015: 05:11 PM