Sukhdev S. Grover, M.D. Associates Detailed Written Order
dba Sleep Center of Greater Pittsburgh | Phone: 724-274-8484 Fax: 412-856-7784
dba Sleep Center of Greater Pittsburgh | Phone: 724-274-8484 | Fax: 412-856-7784
Address:
*
2640 Pitcairn Road, Monroeville, PA 15146
Ordering Physician
*
Sukhdev S. Grover, MD NPI 1295714137 Lic# MD 033946L
A. Ananth Raman, MD NPI 1285613042 Lic# MD 036960Y
Other
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
DME Company
*
Advacare
AHN
Apria
DHS
HCS
Lincare
Medcare
PAO2
REZK
Other
Therapy Type
E0601 - CPAP
E0470 - Bilevel
E0471 - Bilevel S/T
E0471 - Bilevel ASV
Therapy Mode
Dreamstation II Auto CPAP - CPAP mode
Dreamstation II Auto CPAP - Auto mode
Resmed S10 - CPAP mode
Resmed s10 - Auto mode
Dreamstation Auto Bipap - Bipap mode
Dreamstation Auto Bipap - Auto Bipap mode
Resmed Aircurve Auto Bilevel - Bilevel mode
Resmed Aircurve Auto Bilevel - Auto bilevel mode
Philips Bipap S/T with back up rate
Resmed Bilevel S/T with back up rate
Philips Respironics ASV
Resmed ASV
Other
Interface - Cushions- Headgear
A7033 Nasal Pillows 2 per month
A7034 Nasal Mask 1 per 3 months
A7032 Nasal Cushions 2 per month
A7030 Full Face mask 1 per 3 months
A7031 Full face cushion 1 per month
A7035 Headgear 1 per 6 months
Other
Humidifier - Tubing - Filters - Chinstrap
E0562 Humidifier
A7046 Humidifier Chamber 1 per 6 months
A4604 Heated Circuit Tubing 1 per 3 months
A7037 Standard Tubing 1 per 3 months
A7038 Disposable Fine Filters 2 per month
A7039 Reusable CPAP filter 1 per 6 months
A7036 Chinstrap 1 per 6 months
Other
Interface and Size
Pressure Settings
Oxygen
E1390 Oxygen Concentrator
Other
Oxygen Settings
Nocturnal O2 @ 2 l/m with humidity
Nocturnal O2 @ 3 l/m with humidity
O2 bleed in @ 2 l/m
O2 bleed in @ 3 l/m
Other
Pulse Oximetry
Nocturnal pulse oximetry on CPAP/Bilevel 3 weeks after set up
Nocturnal pulse oximetry on CPAP/Bilevel with O2 3 weeks after set up
Nocturnal pulse oximetry on Room air
Other
Diagnosis
*
G47.33 - OSA
R09.02 - Hypoxemia
G47.31 CSA - Central Sleep Apnea
Other
Length of Need
*
1 year
99 months
Other
Submit Data
Should be Empty: