Respiratory Assist Device (RAD) PolicyPhysician Statement of Compliance and BenefitPatients on a Bilevel Sleep Therapy or Noninvasive Positive Pressure Ventilator device must be re-evaluated within 61 to 90 days of initiating therapy by the treating physician to establish the medical necessity for continued coverage by Medicare beyond the first three months.  There must be documentation in the patient's medical record about the progress of relevant symptoms and patient usage of the device up to that time.  Failure of the patient to be consistently using the prescribed device; an average of 4 hours per 24-hour period, during the time of this 61-90 day re-evaluation, would represent non-compliant utilization for the intended purposes and expectations of benefit of the therapy.  This would constitute reason for Medicare to deny continued coverage as not medically necessary.Patient/Beneficiary:_____________________________________________________________________Patient/Beneficiary  Address: _____________________________________________________________________________Physician:____________________________________________________________________________Physician Address: _____________________________________________________________________________Date (RAD) Device Ordered:_____/_____/______Date of Re-evaluation:_____/_____/______Type of Device: (Please check appropriate box)	o  K0532-Bilevel S (w/o backup rate)	o  K0533-Bilevel ST (w/backup rate)Compliance with (RAD) Device:  (Please check the appropriate statement)o  The patient has informed me that he/she is using the device an average of four or more hours per 24-hour period.o  The patient has informed me that he/she is using the device on average for less than four hours per 24-hour period.Benefit with (RAD) Device:  (Please check the appropriate statement)o  The patient is benefiting from the use of the device.  Specific subjective and/or objective benefits are noted in the patient's medical record.o  The patient is not benefiting from the use of the device.I attest to my signature that the information above has been supplied by me and is true to the best of my knowledge.____________________________________________	_____/_____/______Physician Signature					Date of SignatureRespironics	Page 1	Rev 10/22/99