Fill out CMS-484 (Certificate of Medical Necessity - Oxygen) online
Form CMS-484 is the Certificate of Medical Necessity (CMN) specifically for oxygen equipment and supplies. It documents the medical justification for Medicare to cover home oxygen therapy, including the type of oxygen delivery system, flow rate, and clinical findings that demonstrate the medical necessity of supplemental oxygen.
How to fill out CMS-484 (Certificate of Medical Necessity - Oxygen)
Complete patient and supplier information
Enter the patient's name, address, date of birth, Medicare Beneficiary Identifier (MBI) number, and the supplier's name, address, and NSC/NPI number.
Document the oxygen prescription
Specify the type of oxygen delivery system (concentrator, liquid, compressed gas), the flow rate in liters per minute, and the frequency and duration of use (at rest, during exercise, during sleep).
Record the qualifying test results
Enter the arterial blood gas (ABG) or pulse oximetry test results that demonstrate the need for supplemental oxygen. Include the test date, the patient's condition during testing, and whether the patient was on room air or supplemental oxygen.
Physician certification and signature
The prescribing physician reviews the information, certifies the medical necessity of the oxygen therapy, and signs and dates the form. The physician must be the treating physician who ordered the oxygen.
About CMS-484 (Certificate of Medical Necessity - Oxygen)
Who needs this form
Durable medical equipment (DME) suppliers who need to obtain Medicare coverage approval for oxygen equipment and supplies. The prescribing physician provides the medical justification, and the supplier completes the administrative sections.
Where to submit
The DME supplier retains the completed form and submits it as supporting documentation with the Medicare claim to the Durable Medical Equipment Medicare Administrative Contractor (DME MAC).
Source and content freshness
- Filing deadlines may shift for weekends and holidays. Verify due dates with official instructions.
Common mistakes to avoid
- Not including qualifying arterial blood gas or pulse oximetry test results
- Missing the prescribing physician signature and date
- Providing test results that do not meet the Medicare coverage threshold
- Not updating the CMN when the oxygen prescription changes
Frequently asked questions
Is this form free to fill out?
Yes. SimplePDF lets you fill out any PDF form for free, directly in your browser. No account required. For team and business features, see our pricing plans.
Do I need to create an account?
No. You can fill out and download the form without creating an account or signing up.
Is my data secure?
SimplePDF is not a covered entity under HIPAA. Documents are processed entirely in the user's browser and never transit via SimplePDF's servers, on any plan. Read our privacy policy for more details.
Is this legal, tax, or immigration advice?
No. SimplePDF provides form-filling tools and general informational content, not professional advice. Verify requirements with official instructions or a qualified professional.
Can I share a direct link to this form?
Yes! You can create a direct link to any PDF by prefixing its URL with simplepdf.com/. For example: simplepdf.com/https://example.com/form.pdf. Anyone who opens the link can fill out the form immediately in their browser. You can also embed the editor in your own website.
What oxygen levels qualify for Medicare coverage?
Medicare generally covers home oxygen therapy when the arterial blood gas PaO2 is at or below 55 mmHg, or the pulse oximetry SpO2 is at or below 88%, when tested at rest on room air. Coverage may also apply at higher levels (PaO2 56-59 mmHg or SpO2 89%) if the patient has certain conditions such as cor pulmonale, pulmonary hypertension, or erythrocythemia.
SimplePDF provides a tool to fill out PDF forms. We are not affiliated with any government agency or form issuer. It is your responsibility to verify the accuracy and completeness of any information entered. SimplePDF is not liable for errors, omissions, or consequences resulting from the use of filled-out forms.