Letter of Medical Necessity - Heated Humidifier

Date:
Patient Name:
Physician:
Diagnosis:

My patient______________________________ is exhibiting nasal congestion as a response to NCPAP therapy. Left untreated the congestion will limit the ability of the CPAP machine to deliver pressure to the pharynx. This will result in the patient returning to an untreated state of OSA. The pressure produced by the CPAP machine acts as an airway splint allowing the OSA patient regular respiratory breathing during sleep.

I am prescribing Heated Humidification to abate the nasal congestion. This device adds moisture to the nasal mucosa, which reduces the congestion and resistance that is limiting the effective CPAP pressure to the patient. The Heated Humidifier connects between the patient and the CPAP device and is effective in boosting moisture content in the air above and beyond a typical cold-passover humidifier.

The patient is experiencing one or more of the following symptoms:

Nasal Congestion
Dry irritated nasal passages
Bloody nose
Other

Doctor's name:
Address:
Telephone
Doctor's Signature
Date:
Lic. #