The Commonwealth of Massachusetts
Executive Office of Health and Human Services
www.mass.gov/masshealth

Medical Necessity Review Form for Support Surfaces

If you choose to submit this form with your request for prior authorization, the form must be completed by the prescriber and have a copy of the prescription attached. Please refer to the instructions for completing this form provided at the end of this document.  Please print or type all sections.

1. Member name:

2. Member’s MassHealth ID no.:

3. Member’s DOB:

4. Member’s address:

5. Primary diagnosis name and ICD-9-CM code:

6. Secondary diagnosis name and ICD-9-CM code:

Signs and symptoms (Use attachments as needed.)

7. Wound type(s)

 Stage 1 pressure ulcer

 Stage 2 pressure ulcer 

 Stage 3 pressure ulcer 

 Stage 4 pressure ulcer

 Other (describe): 

8. Wound photo(s)

 Photo attached

 Patient refused photo 

 Diagram attached

 Other (specify):

9. Wound description Wound #1 Wound #2 Wound #3 Wound #4

 Wound stage(s):

 Location:

 Length (cm):

 Width (cm): 

 Depth (cm):

 Color:

 Drainage:

 Tunneling:

 Undermining:

Risk factors (Use attachments as needed.)

10. Functional status

11. Mental status

12. Comorbid condition(s)

 Complete immobility

 Limited mobility

 Ambulates with (#) assist 

 Transfers with (#) assist

 Chairbound

 Other (describe): 

 Alert 

 Comatose

 Dementia

 Depression or psychosis

 Other (describe):

 Neurologic (describe):

 Degenerative (describe):

 Malnutrition

 Contractures

 Other (describe):

Diagnostic evaluation (Use attachments as needed.)

13. Nutritional status

14. Incontinence status

15. Drugs affecting wound healing

 Height: Weight: 

 IBW: 

 Enternal supplements:

 TPN supplements:

 Bladder/urine

 Bowel/stool

 Catheter

 Other (describe):

 Oral (describe):

 Topical (describe):

16. Wound care plan includes (Use attachments as needed.):

 Nutritional intervention Wound treatments (describe): 

 Incontinence management 

 Moisture management

 Pain management Other (describe): 

17. Outcome of treatment plan

 a. Over past month, the member’s pressure ulcer(s) have: Improved Remained the same Worsened

 b. Has a conservative treatment program been tried without success? Yes No Does not apply

 c. Was comprehensive assessment performed after failure of conservative treatment? Yes No Does not apply

 d. Is there a trained full-time caregiver to assist patient and manage all aspects involved with use of support surface? Yes No Does not apply 

18. Location where member will use item(s): Home Work Other (specify):

19. Duration of need (number of days): Less than 30 30-60 60-90 Other: (specify):



continued

20. Type of support surface(s) 

21. Description of equipment

 Mattress overlay system (powered)

 Mattress overlay system, nonpowered

 Pressure pads (gel or dry) 

 Air-fluidized bed

 Air-flotation bed, powered

 Semi-electric bed with mattress

 Total electric bed with mattress

 Other (specify): 





22. DME provider 

Company name:

MassHealth provider no. (if available):

Address:

Telephone no. (if available):


23. Prescriber
Name:

Address:

Title:

Telephone no.:

MassHealth provider no.:

Provider UPIN:

24. Person completing form on behalf of prescriber

Name:

Telephone no.:

Organization:

25. Attestation: I certify that the clinical information provided on this form is accurate and complete to the best of my knowledge, and I understand that any falsification, omission, or concealment of material fact may be subject to civil or criminal liability.


Prescriber’s attestation (signature) Date (mm/dd/yy)

See instructions for completing this form on the next page. u

Instructions: Complete all applicable fields on the form. Print or type all sections.


Item 1

Member’s Name

Enter the member’s name as it appears on the MassHealth card. 

Item 2

Member’s 
MassHealth ID no.

Enter the member’s MassHealth identification number, which appears beside the member’s name on the MassHealth card. 

Item 3

Member’s DOB 

Enter the member’s date of birth in month/day/year order.

Item 4

Member’s address

Enter the member’s permanent legal address (street address, town, and zip code). 

Item 5

Primary diagnosis 

Enter the primary diagnosis name and ICD-9-CM code that correspond to the condition for which the support surface is being requested.

Item 6

Secondary 
diagnosis 

Enter the secondary diagnosis names and ICD-9-CM codes (up to 3 codes) that correspond to other medical conditions associated with the need for the requested support surface. Enter “N/A” if not applicable.

Item 7

Wound type(s)

Place a checkmark beside all wound types that apply. If checking “Other,” specify the type not listed (for example, non-healing wound) in the space provided. Use attachments as needed.

Item 8

Wound photo(s)

Place a checkmark beside all types of documentation provided. If checking “Other,” specify the type of documentation in the space provided. Attach the applicable documentation for each item checked.

Item 9

Wound description

For each wound, enter in the spaces provided, the wound stage, location, size (length, width, depth), color, drainage, tunneling, and undermining. Use attachments as needed. 

Item 10

Functional status

Place a checkmark beside all statuses that apply. If checking “Other,” specify the status not listed in the space provided. Attach clinical information about all items checked. 

Item 11

Mental status 

Place a checkmark beside all statuses that apply. If checking “Other,” specify the condition not listed in the space provided. Attach clinical information as needed.

Item 12

Comorbid 
condition(s)

Place a checkmark beside all conditions that apply. When indicated, specify the conditions in the space provided. Attach clinical information about all items checked. 

Item 13

Nutritional status

Enter member’s height in inches, weight in pounds, ideal body weight (IBW) in pounds, and type of enteral and parenteral supplements used. Attach clinical information as needed.

Item 14

Incontinence status

Place a checkmark beside all that apply. If checking “Other,” specify the status not listed in the space provided.

Item 15

Drugs affecting 
wound healing

Place a checkmark beside all that apply. Describe the types of oral or topical medications affecting wound healing in the space provided.

Item 16

Wound care plan 
includes

Place a checkmark beside all that apply. If checking “Wound treatments,” describe the treatments used (for example, calcium alginates or hydrogel). If checking “Other,” describe the treatments not listed.

Item 17

Outcome of 
treatment plan

Place a checkmark beside the appropriate response for each question asked.

Item 18

Location where 
member will use 
item(s)

Place a checkmark beside all locations that apply to use of the product requested. If checking “Other,” specify the location (for example, skilled nursing facility, end stage renal disease facility) in the space provided.

Item 19

Duration of need 
(number of days)

Enter total number of days that prescriber expects the member to require use of the items requested. If “other” is checked fill in blank. 

Item 20 

Type of support 
surface

Place a checkmark beside all requested items. If checking “Other,” specify the type of support surface not listed in the space provided. 

Item 21

Description of 
equipment

Enter a description of the item(s) requested (for example, accessories, supplies, or options).

Item 22

DME provider 

Enter the company name and address of the provider who will supply the support surface(s) being requested. If available, also provide the DME provider’s telephone number and MassHealth provider 
number. 

Item 23

Prescriber 

Enter the physician’s/clinician’s name, address, and telephone number where he or she can be contacted if more information is needed. Include the prescriber’s MassHealth provider number, or if the prescriber is not a MassHealth provider, enter the prescriber’s unique physician identification number (UPIN).

Item 24

Person completing form on behalf of prescriber

If a clinical professional other than the treating clinician (for example, home health nurse or wound-care specialist) or a physician employee answers any of the items listed he or she must print his or her name, professional title, and name of employer (organization) where indicated. 

Item 25

Attestation 

The prescriber must attest that the clinical information provided on the form is accurate and complete to the best of the prescriber’s knowledge by signing this field. 

Note: Prior-authorization requests with incomplete medical necessity documentation may be returned for more information or denied. Please refer to the MassHealth Guidelines for Medical Necessity Determination for Support Surfaces for further information about submitting required clinical documentation. 

MNR-SS (04/06)