MASSHEALTH PRESCRIPTION AND MEDICAL NECESSITY REVIEW FORM 

FOR AMBULATORY INFUSION (INSULIN) PUMPS 


Sections 1, 2, 3, 4, 5, and 6 must be completed by the provider of durable medical equipment and supplies (DME). 
Sections 4A (shaded below), 5A (shaded below), and 7 must be completed by the prescribing provider or his/her employee. 
Section 8 must be completed by the prescribing provider. 


SECTION 1 

Date of Delivery / / Member Name 
Address Telephone No. 
MassHealth ID No. Date of Birth / / Gender Height Weight 
Primary ICD-9 Code Description 
Secondary ICD-9 Code Description 

SECTION 2 


Prescribing Provider’s Name 
Address 

Telephone No. 

SECTION 3 

Name of Provider of DME 

Address 

Telephone No. 

NPI No. 

Fax No. 

NPI No. 

Fax No. 

SECTION 4 Ambulatory Infusion (Insulin) Pumps Only 
Please enter the appropriate HCPCS code, modifier, and description of equipment. 
SECTION 4A 
(Must be completed by the prescribing provider or by 
the prescribing provider’s employee.) 
Description of Item(s) Being Requested HCPCS 
Code 
Modifier Length of Need 
SECTION 5 Pump Supplies Only 
Please enter the appropriate HCPCS code, modifier, and description of the supplies. 
SECTION 5A 
(Must be completed by the prescribing provider or by 
the prescribing provider’s employee.) 
Description of Item(s) Being Requested HCPCS 
Code 
Modifier Quantity Monthly Number of Refills 

SECTION 6 Provider of DME Attestation, Signature, and Date 

I certify under the pains and penalties of perjury that the information on this form and any attached statement that I have provided has been reviewed and 
signed by me, and is true, accurate, and complete, to the best of my knowledge. I also certify that I am the provider or, in the case of a legal entity, duly 
authorized to act on behalf of the provider. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or 
concealment of any material fact contained herein. 

Signature of provider of DME (Signature and date stamps, or the signature of anyone other than the provider of DME or a person legally 
authorized to sign on behalf of a legal entity, are not acceptable.) : 

Printed legal name of provider 

___________________________________________________________________________________________________________________________________________________________________________________Date______/_____ /_________________________________ 

Printed legal name of individual signing (if the provider is a legal entity) 

MNR-IP (05/11) continued on back 



Member Name: ____________________________________ ____________________________________ 

SECTION 7 
Section 7 must be completed by the member's prescribing provider or the provider’s staff. Please attach any pertinent information (for example, 
lab tests, medical history and physical examination, or clinical notes, etc). 


a. What co-morbidities are present? Please list the ICD-9 code. 
Retinopathy 
Nephropathy 
Neuropathy 
Other: 
b. What was the date of the member’s most recent HbA1c? What was the value? 
Other relevant tests (specify):_________________________________ 
c. How many injections of insulin does the member self-administer a day? 
one to three times a day 
three to six times a day 
six to nine times a day 
10 or more times a day 
Other (specify): 


d. Does the member frequently adjust his/her insulin dosage? ………………………………………………………………………………... 
Yes 
No 
Please explain how often the dosage is adjusted. 
How long has the member been adjusting his/her dosage of insulin? 
e. Does the member have a history of recurring hypoglycemia? …………………………………………… 
Yes 
No How often? 
f. Does the member have wide fluctuations in blood glucose before mealtime? ……………………………………………………………. 
Yes 
No 
Please list the three most recent ranges 
From___ to___ mg/dL 
From___ to___ mg/dL 
From___ to___ mg/dL 
g. Does the member have dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL? …………………………….. 
Yes 


No 
How often in the last 30 days? 

h. Does the member have a history of severe glycemic excursions? ………………………………………………………………………….. 
Yes 

No 
Please explain. 

i. 
Does the member have a history of prior treatment with MDIs (multiple daily injections) that have been tried and not been effective in managing 
blood sugars or medical symptoms? ………………………………………………………………………………………………………….. … 
Yes 
No 
Please explain. 
j. Is the member motivated to maintain optimal control of his/her diabetes? ……………………………………………………………………. 
Yes 
No 
Please explain. 
k. Does the member demonstrate a willingness to adhere to a proper diet and exercise regimen? ………………………………………. 
Yes 


No 
Please explain. 

l. Does the member have the ability to operate the pump?........................................................................................................................ 
Yes 

No 

SECTION 8 
Prescribing Provider’s Attestation, Signature, and Date 

I certify under the pains and penalties of perjury that I am the prescribing provider identified in Section 2 of this form. Any attached statement on my 
letterhead has been reviewed and signed by me. I certify that the medical necessity information (per 130 CMR 450.204) on this form is true, accurate, and 
complete, to the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or 
concealment of any material fact contained herein. 

Prescribing provider’s signature (Signature and date stamps, or the signature of anyone other than the prescribing provider, are not 
acceptable.) 

Check applicable credentials 


MD 
NP 
PA 
Printed name of prescribing provider 
Date / / 




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Instructions for Completing the MassHealth Prescription and Medical Necessity Review Form for Ambulatory Infusion Pumps 
(Insulin Pumps) 

Sections 1, 2, 3, 4, 5, and 6 must be completed by the provider of DME. 
Sections 4A, 5A, and 7 must be completed by the prescribing provider or his/her employee. 
Section 8 must be completed by the prescribing provider. 
Instructions for the 
Use of this Form 
Providers of DME should use this form when obtaining a Prescription and Letter of Medical Necessity from the 
member’s prescribing provider for Ambulatory Infusion Pumps (Insulin Pumps), and as an attachment to a prior 
authorization (PA) request for insulin pumps. Providers of DME are responsible for ensuring compliance with 
applicable MassHealth regulations and guidelines when using this form. MassHealth reserves the right not to accept 
the form if it is completed improperly, or if the provider has failed to meet applicable MassHealth regulations, 
requirements, and guidelines, including without limitation medical necessity requirements. Please refer to the 
MassHealth Guidelines for Medical Necessity Determination for Ambulatory Infusion Pumps (Insulin Pumps) 
for further information about required clinical documentation and information that must be submitted for PA requests 
for ambulatory infusion pumps (insulin pumps). A copy of this completed form (including all attachments and 
supporting documentation) must be maintained in the member’s medical record at the prescribing provider’s office 
and at the provider of DME’s office. 
Section 1 
Enter the date of delivery of ambulatory infusion pumps (insulin pumps) at the top of the form. The date of delivery 
on this form must match the date on the delivery slip. Enter the member’s name, MassHealth member ID, address 
(including apartment number if applicable) telephone, date of birth, gender, height, weight, and applicable ICD-9 
diagnosis code(s) with their descriptions. 
Section 2 Enter the prescribing provider’s name, NPI, address, telephone and fax number 
Section 3 Enter name of provider of DME, NPI, address, telephone, and fax number. 
Section 4 
Enter the description of the ambulatory infusion pump(s) (insulin pump(s)) being requested, the correct HCPCS 
code(s), and the modifier(s). Please do not list pump supplies in Section 4, but separately complete Section 5 for 
that purpose. Please be sure to use the correct modifier for the length of time you are requesting. 
Section 5 Enter the description of the pump supplies being requested, if any, for use with the ambulatory infusion pumps 
(insulin pumps), along with the correct HCPCS code(s) and modifiers. 
Section 6 
The provider of DME must sign and enter the date the form was completed. By signing the form, the provider is 
making the certifications contained above the signature line. Note: Signature and date stamps, or the signature 
of anyone other than the provider of DME or a person legally authorized to sign on behalf of a legal entity (ifthe provider of DME is a legal entity), are not acceptable. 
Sections 4A, 5A, and 7 must be completed by the prescribing provider or his/her employee. 
Section 4A 
The prescribing provider(or his/her employee) must enter the total number of months that the prescribing provider 
expects the member will require use of the ambulatory infusion pump (insulin pump). The total number of months 
cannot exceed 13 months from the date of the original prescription. 
Section 5A The prescribing provider or his/her employee must enter the total monthly quantity of pump supplies and the number 
of refills. The total number of months cannot exceed 13 months from the date of the original prescription. 
Section 7 The member's prescribing provider or his/her staff must complete the medical justification for the requested 
product(s). This section must be filled in, and applicable supporting documentation must be attached. 
Section 8 must be completed by the prescribing provider. 
Section 8 
The member's prescribing provider listed in Section 2 of this form must review all information completed on and 
attached to this form, and must sign and date the form. By signing the form, the prescribing provider is making the 
certifications contained above the signature line. The form must be signed by the member's prescribing 
provider, who must be either the member's physician (MD), nurse practitioner (NP), or physician assistant 
(PA). The prescribing provider must check the applicable credential(s). 

If you have any questions about how to complete this form, please contact MassHealth Customer Service at 1-800-841-2900. 

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