Posts Tagged ‘Letter of Justification for Stander’

Sample LMN for Evolv Youth Stander from Altimate Medical

Wednesday, October 19th, 2011

Letter of Medical Necessity #1
RE: John Doe Date of Birth: 11-18-87
DX: Microcephaly/CP Funding: MA
Parent: Phone:
Address: MN Date: 01-12-99

General Medical Condition:

____is an 11 year old male referred to Rehab Center by Dr._____. ____has a birth history significant for partial deletion of the long arm of the 1st chromosome. _____ also had a left brachial plexus injury, which affected his diaphragm. ____ was admitted to the NICU for 4 1/2 weeks. He has history of seizures and apnea. His seizures are controlled by medication at this time. Medications include Benadryl and Depakote. Past surgical history includes derotation osteotomies 4 years ago, hardware removal 3 years ago and abdominal surgery 2 years ago. He also has history of metatarsal fracture 1 1/2 years ago. Per mother, ____s cognition is 24
months. He enjoys music. He has a hearing impairment and wears bilateral hearing aids. ___ received Botox injections to bilateral hamstrings on 8-10-98 and began physical therapy in the pool 9-98. Primary focus is to assist ____ out of his flexed position.

Since____s hip surgery, he has been unable to tolerate LE weightbearing and has developed contractures in his hips, knee and ankles in a flexor synergy. ____has made gains in the pool with LE extension and is beginning to weightbear with assistance. Because ____ has grown to significant size, 4’8″ and 110 lbs., it is unreasonable to work on standing without the assist of a standing frame. He
requires maximal assist of one or two people to maintain stance for greater than a brief transfer secondary to limited extension and strength in weightbearing on land. ____ requires maximal assist to transfer. He needs maximal assistance for transitions into/out of his chair. ____does not ambulate at this time. Per parent, he did take a few steps with assistance for balance prior to his hip
surgery. ____ can sit independently, his primary form of mobility is a modified bunny hop for short distances ( 3-5-feet) . ____ spends a majority of his day in his wheelchair.

Current Program:
At this time ____ does not have a stander available to him at school or home. Secondary to his contractures, ____ will not tolerate a
standard standing frame that requires knee extension along with dorsiflexion at his ankles. But more importantly, it would be
unsafe and impractical to try to lift and position him into a standing frame (prone or supine). _____s mother does his transfers
independently at home and needs a support/standing frame that ___ can be positioned in with one person. ____ also needs a type
of stander that can be slowly moved into extension as he is able to tolerate. ____ will be in his stander daily with parent or PCA.
With increased tolerance of weightbearing and LE extension, ____ will in the future be able to assist with stand pivot transfers into
and out of his wheelchair, toilet and bed.

Equipment Trial:
___ underwent a trial with the EasyStand Evolv which he tolerated well. He demonstrated his tolerance in one session at Rehab
Center and then the stander was utilized at his school for a week which was a positive experience for ____ as well as his therapist
and teacher. He was able to stand for 25 minutes the first session. He was assisted to a sitting position in the EasyStand from his
wheelchair by his mother. ____ was then slowly and gently elevated into weightbearing position with slow increase in hip and knee
extension. He was able to tolerate -25 degrees of knee extension and -30 degrees of hip extension. ___ was able to tolerate more
extension in the stander for a prolonged period of time versus when 2 or more caregivers are attempting to support his stance with -
45 to 50 degrees of knee and hip extension. The other plus for this stander is that ___ will be able to utilize this stander into adulthood.

Recommended Equipment:
Recommended at this time is the EasyStand Evolv with the 19” contoured back and a seatbelt. It has four seat depth adjustments for growth and chest strap for additional support and safety. If _____ does not address his hip and knee contractures through weightbearing and prolonged stretch now that he is making some progress towards extension, his future will hold more surgery and equipment for transfers. (Hoyer) ____ will benefit from addressing his contractures and limited weightbearing now to ensure his functional independence and participation in transfers in the future.

Jane Doe , PT Dr. John Doe

This copy is provided by Active American Mobility and Medical Supply. No restrictions on distribution. For more information contact us.
Contact Patrick Boardman 281-495-4400
Special thanks to Altimate Medical for this letter.

Ehlers Danlos Syndrome Letter of Medical Neccessity for K0005 Manual Wheelchair

Wednesday, October 19th, 2011

April 18, 2010
To: Medicare (or other insurance carrier)

Re: ————-
DOB: 00-00-0000
HICN: ————-
Diagnosis/Problems: Ehlers Danlos Syndrome; Osteoporosis; HTN; Multiple Hematomas;
Gait Dysfunction; Scoliosis; Chronic pain; History of Tendon Rupture;
Left hip replacement(10/04); wrist subluxation bilaterally;
Decubitus Ulcer

Subject: prescription for ultra-lightweight manual wheelchair and seating equipment

To Whom It May Concern,

—————— is a 40 year old male with multiple medical problems secondary to his Ehlers Danlos syndrome which effects the integrity of his connective tissues throughout his body. As a result of this condition, he is unable to ambulate secondary to inadequate connective tissue in his feet to support the weight of his body. When he attempts to stand/ambulate he is loading his weight directly onto the bones in his feet which can result in tearing of the skin across planter surface and severe pain throughout lower extremities. His ambulation is also inhibited by restricted active range of motion at ankles secondary to surgical fusion of ankles due to hyper-mobility as a result of loss of connective tissues in lower extremities. In addition, with the loss of connective tissue, his joint stability and lower extremity strength is significantly impaired and inadequate for safe ambulation.

————– is dependent upon a wheelchair for independent functional mobility at home, work and in the community but his ability to propel is restricted by loss of connective tissue in upper extremities which results in skin tears in hands. His upper extremity strength/endurance is fair but the task of propelling a standard/lightweight manual wheelchair is significantly difficult for him and he is unable to safely load the wheelchair in/out of vehicles as needed due his risks for skin damage which is further complicated when having to lift a heavy object such as a wheelchair. In addition, upper extremity function and prehensile patterns are inhibited by wrist subluxation bilaterally. He has also required multiple tendon repairs in hands/wrists bilaterally resulting in either restricted or hyper range of movement at joints.

Approximately 3 weeks ago, ————— received a new wheelchair as recommended. It was projected that by the time he received this equipment that he would no longer require elevation of his legs/feet. However, he continues to experience restricted range of movement at times in knee flexion bilaterally that inhibits his ability to position his lower extremities on 70 degree leg rests provided with the wheelchair. In addition, he has become more comfortable with his legs in variable positions of elevation taking the physical stress off of his knees and reducing his risks for further skin tears.

Page 2/—————

In order to provide for safe supported positioning of lower extremities, accommodation of restricted knee flexion and to reduce risks for furhter injury to knees and/or skin damage in lower extremities, the following equipment is recommended and is considered medically necessary:

1) Ki Catalyst V wheelchair with articulating elevating leg rests with adjustable angle footplates to accommodate ________________
2) Natural Fit handrims to accommodate tensile strength and grip in hands and to allow client to propel chair manually.
3) Other accessories (Insert here and add medical justification)

Thank you for your attention in this matter.

Muscular Dystrophy Sample Letter of Medical Neccessity for Power Wheelchair and Seating

Wednesday, October 19th, 2011


To: Humana

Re: ————————–
DOB: 00-00-0000
SS#: ————————-
policy#: —————————

Diagnosis: Muscular Dystrophy

Subject: prescription for power wheelchair and seating equipment

To Whom It May Concern,

——————— is a 19 year old male patient of mine with the above diagnosis who is non-ambulatory and is unable to propel any type of manual wheelchair. He is dependent upon a power wheelchair for all functional mobility at home and in the community. He has recently graduated from highschool and is preparing for enrollment in a college later this year. He requires a new power wheelchair base with upgraded electronics and custom fitted seating and drive controls to support his independent functional mobility at home, in the community and to support his independent access on his college campus.

Currently, ——- is using an Invacare power wheelchair (serial# 00000000) that is several years old. There have been several repairs made to this wheelchair in the past few months and there is current concern over needing to replace drive motor(s) and/or gear boxes. All 4 tires are severely worn and in need of replacement as well. ——-also reports having increased difficulty driving this power wheelchair up inclines and maintaining the position of his right upper extremity to allow for joystick access with right hand. He is unable to utilize the foot supports on this chair because of the overall length of the power wheelchair with them attached. His access/mobility is restricted in turning thru doorways at home as well as maneuvering thru his van, hallways and other spaces at home and in the community. The seat back on the current power wheelchair provides no contact or support when ——– is seated upright or in moderate tilted angles and only provides minimal support when he is in full tilted postures. There is no accommodation designed in the current seating or power seat functions for the significantly hyper-lordotic spine/trunk posture that dominates ——– sitting position/posture. Consequently, he sits unsupported the majority of the day resulting in significant motor and respiratory fatigue. Finally, the current power wheelchair does not provide the electronic interface modules to environmental access controls or remote computer access controls which ——- desires and will need to further facilitate his independence at home, school and in the community/work environment(s).

Due to the nature of his diagnosis, ——–is dependent for all transitional mobility, transfers, bed mobility, re-positioning, and ADL’s including feeding. He is unable to stand or bear weight on lower extremities and he is unable to sit unsupported. He recently began using a bi-pap machine Page 2/————————-

at night due to respiratory compromise. He also has a cardiomyopathy that is being treated medically. His upper extremity functional mobility is significantly limited by his progressive loss of motor function. Currently, he can operate the power wheelchair using his right hand when the forearm is supported on a padded trough. He grasps the extended joystick between his first and second fingers with his wrist in extension and ulnar deviation and his forearm in neutral or slightly supinated. He primarily uses gross motor movements at shoulder to push or pull hand in controlling the joystick. Alternative drive controls were explored with —— but did not appear to support his independent control of the joystick as well as his current method. However, he is having increased difficulty moving his forearm across the arm trough surface material due to excessive friction but also reports being unable to support his forearm/hand in position when tilted if forearm trough becomes wet/slippery from his perspiration.

———- presents with an anteriorly rotated pelvis and hyper-lordotic spine/trunk that has been stabilized with rods in 2000. His head control is good when he is in upright seated postures but he requires posterior and lateral support of his head when he moves into tilted postures. As indicated, ——- cannot seat upright without support including lateral trunk supports, anterior chest support and posterior back support. His righting reactions and protective reflexes are delayed and/or impaired and he is unable to perform independent pressure relief techniques due to upper extremity weakness. Therefore, he is at significantly increased risks for skin breakdown.

In order to provide safe supported seating, accommodate for postural abnormalities, facilitate independent functional mobility and reduce risks for secondary complications such as skin breakdown, contractures and deformity as well as facilitate environmental access and functional independence at home, school and in the community, the following equipment is recommended and is considered medically necessary:

1) Invacare TDX-SP power base (short) with MARK VI electronics; transport
brackets; 8 inch casters with shock forks; 14 x 3 inch foam filled tires; compact 1812 joystick with display; Gatlin adjustable joystick mount; straight handle flexible joystick extension; Communication Module 1 &2 for environmental/computer access thru power wheelchair electronics.

2) Motion Concepts Ultra-Low TRx-CG power seating system for Invacare Storm Arrow base with 55 degrees power seat tilt; 174 degrees power seat recline/30 degrees power seat pre-cline; TRx elevating seat module; 16w/18d seat pan with 2 inch narrower seat back; 19 inch back height with 22 inch tall back canes and standard Rehab back pan and pad; reclining height adjustable arm supports; TRx elbow blocks; 2 pairs of TWB lateral supports for trunk and hip guide alignment/support; fixed 90 degree center mount interface bracket with flip-up footplatform 11in x 10 inch; enhanced 2-5 function electronics to allow control of drive/seat functions thru joystick with standard scan mode select upgrade; Trx M16 splitter and accessory port power supply to accommodate environmental/computer access thru power wheelchair electronics. The power pre-cline function is needed to facilitate back support and accommodate for ———– abnormal structural trunk/spinal posture; power pre-cline is not Page 3/——————–

available without power recline function; power tilt is needed for pressure relief and to facilitate trunk posture/alignment improving head control and supporting respiration, communication and swallowing; the footplatform is required for lower extremity support.

3) AEL chest support strap to fit between lateral trunk supports to prevent forward trunk collapse.

4) AEL arm troughs with adjustable hardware mounts and wrist straps to facilitate positionijng of upper extremities and reduce risks for injury to upper extremities from falling off of arm supports when in tilted postures or when operating power wheelchair drive function.

5) Freedom Design custom headrest with removable cover to support head when in tilted positions and when driving power wheelchair.

6) Freedom Design mild contour seat insert to accommodate for pelvic and lower extremity positioning and to reduce risks for contractures, deformity and skin breakdown.

Thank you for your attention in this matter.


————————–, MD

This copy is provided by Active American Mobility and Medical Supply. No restrictions on distribution.
Contact Patrick Boardman 281-495-4400