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Certificate of Medical Necessity Form

M ID # has been evaluated for sleep disordered breathing or obstructive sleep apnea . A sleep apnea study needs to be performed and is medically necessary based upon the following clinical symptoms.
The patient history reveals the following conditions:
excessive daytime somnolence
snoring
alling asleep while driving
Polycythemia
pedal edema
wakens with the sensation of choking & gasping
wakens with headache
caffeinated beverages (within 4 hrs. of sleep)
smoking > 1 pack/day
 obesity
depression
hypertension
nocturia
impotency
GE reflux
heart disease
alcohol consumption
allergic rhinitis
type II diabetes
The patient's sleep observer gives the following description of sleep abnormalities:
soft or loud snoring
observed apnea during sleep
Medical examination has revealed:
hypertension
pedal edema
weight
 maxillo-mandibular malformation
adeno-tonsillar enlargement
height
The above factors indicate the high probability of sleep apnea, upper airway resistance syndrome, or hypoventilation, which should be treated if diagnostically confirmed through a sleep study.