10. Objective Test Results - All lab reports must be attached, including tracing for each PFT. The following data (10A through 10D for a PFT; 

10E through 10I for an ABG) MUST BE reported below OR on the attached lab report.

U.S. Department of Labor 

Office of Workers' Compensation Programs 

Division of Coal Mine Workers' Compensation

Certification of Medical Necessity

OMB No.: 1240-0024

Expires: 05/31/2024

Completion of this form and prior approval is required when making an initial request for the Department of Labor to authorize 

reimbursement charges for equipment and home nursing care (30 U.S.C. 901 et seq. and 20 CFR 725.705 and 725.706). If 

granted, the authorization covers a maximum period of one (1) year, subject to renewal. Fill in all applicable items. (See DOL 

Reimbursement Standards under Item eleven (11)). This form must be signed and dated by the treating physician. Collection of 

this information is required to obtain a benefit. Persons are not required to respond to this collection of information unless it displays 

a currently valid OMB control number.

1. Patient's Name and Mailing Address 2. Telephone Number 3. DOL’s Case ID Number

4. Date of Birth

6a. Date(s) of last hospitalization 6b. Condition(s) treated while in hospital

From:

To:

8b. Requested Duration of Prescription for DME 

or Home Nursing (see 11c.) Original (New)

Recertification Beginning 

Date: (Renewal)

9. EQUIPMENT OR SERVICE PRESCRIBED (SEE Item 11, FOR CORRESPONDING DOL REIMBURSEMENT STANDARDS)

9a. Oxygen Delivery Equipment (11 a.) Prescription: Flow Rate (L/M) Est. Hrs./Day

9b. Other DME 9c. Prescription for Medical Services

Home Nursing Care (See 11c.)

(Note: Patient's condition is considered ACUTE if test was taken during a hospitalization for a covered pulmonary condition.)

A. Pulmonary Function Test (see 11e.) B. Check as appropriate (if "poor", explain in Item 12 "Comments")

Miner's Cooperation: Good Poor Date of test:

Miner's ability to understand instructions and follow directions: Acute

Good Fair Poor

Fair

Results 

(Best Effort) 

Chronic

C. Was equipment calibrated before the test? 

Yes No (Explain Under Item 12.)

Bronchodilation Predicted

Before

D. Testing Facility Name and Address:

FEV L/BTPS

FVC L/BTPS

F. Air Intake: On room air On O2 @

G. Time Sample Drawn

Yes

No

H. Was equipment calibrated before the test?

Yes No (Explain Under Item 12.)

E. Arterial Blood Gas Test (see 11e.)

Date of test: Pt.'s condition:

Acute

Chronic

Results: PO2 PCO2 PH

I. Testing Facility Name and Address

CM-893 (REV. 05/21)

State: Zip:

City:

State: Zip:

Name:

Line 1:

Line 2:

City:

State: Zip:

Ending 

Date:

5. (blank)

Tank O2 With Flowmeter and Humidifier O2 Concentrator O2 Liquid System

Portable Unit (Gaseous) O2 Liquid System With Portable Liquid

Manual Hospital Bed/Mattress (11b.)

Semi-electric Hospital Bed (11b.)

Wheelchair (11d.)

Other (Explain in Item no. 12.)

After

 Pt.'s condition:

LPM

 Iced Time Sample Analyzed

Name:

Line 1:

Line 2:

Line 2:

Line 1:

Name:

City:

1

MM DD YYYY

MM DD YYYY

7. Pulmonary Condition(s) for which this prescription is written: 8a. Type of Prescription
12. Comments:

13. PHYSICIAN/PROVIDER INFORMATION

a. Prescribing Physician's Name, Address and Phone Number (print or type) b. Are you the patient's regular physician or are you actively treating this patient? 

If NO, explain why you are prescribing the equipment or services on this form.

d. Date that the prescribed treatment or service is authorized

to begin:

c. Date of Visit (the date you examined the patient and made the

decision for this prescription):

e. I certify that I am the current treating physician (or have provided an explanation in 13b. above) and that the prescribed equipment and/or services on this 

form are medically necessary for treating this patient’s covered pulmonary condition. I also certify that all data accompanying the submission is an accurate 

representation of the test results. Any statement on my letterhead attached hereto, has been reviewed and signed by me. I understand that any falsification, 

omission, or concealment of medical fact may subject me to civil or criminal liability.

Physician's Signature Date

f. Name, Address, Phone No., and PROVIDER NO. of provider who is supplying the 

equipment or service:

TWO FILING OPTIONS: 

 1. To file electronically, submit completed form and accompanying 

 medical documentation to the COAL Mine Portal: 

 https://eclaimant.dol.gov/portal/?program_name=BL

 2. To file by mail, submit completed form and accompanying 

 medical documentation to: 

U.S. Department of Labor 

OWCP/DCMWC/CMR Correspondence 

PO Box 8307 

London, KY 40742-8307 

 For further information call TOLL FREE: 1-800-638-7072.

PRIVACY ACT

The following information is provided in accordance with the Privacy Act of 1974, 5 U.S.C. 552a. (1) Collection of this information is authorized by the Black 

Lung Benefits Act (30 U.S.C. 901) and implementing regulations (20 CFR 725.706 and 725.707). (2) The information in this form will be used to ensure that 

the program covers the medical treatment prescribed and to ensure accurate medical provider information for payment of medical bills. 

Completion of this form is required to obtain or retain a benefit (30 U.S.C. 901). Failure to provide the requested information and documentation may result 

in bill payment delays or denial. (3) This information may be used by other agencies or persons handling matters relating, directly or indirectly, to processing 

this form including liable coal mine operators and their insurance carriers; medical professionals in obtaining medical services or evaluations; contractors 

providing automated data processing or other services to the Department of Labor; representatives of the parties to the claim; and federal, state or local 

agencies. (4) Furnishing all requested information will facilitate accurate and timely payment of medical services to the provider. (5) This information is 

included in a System of Records, DOL/OWCP-2 and DOL/OWCP-9, published at 81 Federal Register 25765, 25858, and 25866 (April 29, 2016), or as 

updated and republished.

Public Burden Statement

We estimate that it will take an average of 20-40 minutes to complete this collection of information, including time for reviewing instructions, searching 

existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments 

regarding these estimates or any other aspect of this collection of information, including suggestions for reducing this burden, send them to the Division of 

Coal Mine Workers’ Compensation, U. S. Department of Labor, Room N-3464, 200 Constitution Avenue, N.W., Washington, DC 20210. DO NOT SEND 

THE COMPLETED FORM TO THIS OFFICE.

11b.

11c.

11d.

11e. 

 11. DOL/DCMWC REIMBURSEMENT STANDARDS

Hospital Bed/Mattress: must be justified by PFT results indicating an FEV1 equal to or less than 40% of predicted, or chronic hypoxia (pO2 of 55 

mmHg or less). PFT – Test results with tracings and flow volume loop must be attached. ABG – Test strip must be attached.

Prescriptions for home care: must include objective test results or comparable clinical data, explanation why the patient is homebound, and a 

specific schedule of services to be rendered, including the total number and frequency of prescribed visits. Indicate the type of medical professional 

(PA, RN, LPN, RT) providing care. Use Item 12, below, and/or attach separate sheet.

Wheelchair is not a commonly covered item. Requests must include medical support data and will be evaluated individually. Data must support the 

wheelchair need because of a severe pulmonary impairment.

ALL CMN supportive test results: must be dated 2 months or less prior to prescription for services. Recertification services for home nursing care 

and equipment must be reviewed yearly or at the expiration date. PFT – Test results with tracings and flow volume loop must be attached. ABG – 

Test strip must be attached.

NOTE: Prescription for indefinite services or those without required objective test data will be returned for specific information. If your request is 

rejected because your patient’s medical condition does not meet DOL reimbursement requirement standards, you may submit other medical 

evidence to support your prescription request. All evidence will be considered.

CM-893 PAGE 2 (REV. 05/21)

Line 1: City:

Line 2: State: Zip:

Phone:

Line 1: City:

Line 2: State:

Yes No

Zip:

Name:

Name:

Phone: Provider No.: 

Notice

If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive help from OWCP in 

the form of communication assistance, accommodation and modification to aid you in the claims process. For example, we will provide you with copies of 

documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes to account for the 

limitations of your disability. Please contact our office or the claims staff to ask for assistance.

11a. For Home O2 delivery equipment: requires a pO2 value of 60 mmHg or less on room air during a chronic state with corresponding pCO2 and pH 

values. If the ABG is done while the patient is on O2, the pO2 standard = 80 mmHg for all oxygen equipment (See 11e). All medical evidence to 

support your request will be considered.

If the patient is homebound or non-ambulatory, or if other circumstances related to his/her condition prevent the sample from being analyzed within 30 

minutes, the prescribing physician may submit a narrative rationale explaining the circumstances and substantiate the medical necessity for the item or 

service prescribed.