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CENTERS FOR MEDICARE & MEDICAID SERVICES. Form Approved OMB. No. 0938-0679. Expires 02/2024. CERTIFICATE OF MEDICAL NECESSITY. DME 484.3. CMS-484— OXYGEN. Certificate of Medical Necessity for Home Oxygen (The CMN may act as a Medical Records supporting that the beneficiary meets the basic coverage criteria CMS adopts the diagnostic criteria used by the International Headache Society to form a definitive diagnosis of. CH. Therefore, the home use of oxygen toBefore submitting an initial oxygen claim to Medicare, a DME supplier must have the if ordering portable oxygen (also must be noted on the CMN). Certificate of Medical Necessity (CMN) – Medicare determines coverage of home oxygen based on the patient's blood gas test results. The CMN must be completed, signed, and dated by the ordering physician. According to Medicare guidelines, oxygen suppliers must submit appropriate CMNs with