Date:
To: Medicare
Re: ————————
DOB: 00-00-0000
HICN: ———————–
Diagnosis/problems: ALS
Subject: prescription for power wheelchair and seating/positioning equipment
To Whom It May Concern,
——————- is a 74 year old male patient of mine who was diagnosed with ALS in January of 2006. He has presented with signiciant functional decline over the past few months such that he was ambulating 1 mile a day in December of 2005 and now cannot stand independently. He is unable to ambulate or propel a manual wheelchair of any type secondary to his diagnosis. Therefore, it is recommended that he be provided a power wheelchair with power seat functions to support his functional independence and safety at home.
———— lives with his wife in a single family home that is accessible to a power wheelchair. He has been provided a loaner power wheelchair to use in his home and is demonstrating safe operation and maneuvering of the power wheelchair throughout his home. He requires moderate assistance with ADL’s and continues to be able to feed himself orally although he is reporting occasional coughing with swallowing. He is using a thickener for his liquids to facilitate safe swallowing. His sitting posture and trunk control are significantly influenced by gravity and he frequently collapses into flexed postures a as a result increasing his risks for contractures/deformity as well as compromising his position for respiration and/or swallowing. —————— is unable to independently perform pressure relief and/or re-position himself resulting in increased risks for skin breakdown and/or development of contractures. In addition, he is experiencing urinary incontinence which further increases his risks for skin breakdown.
In order to provide safe supported sitting, facilitate independent postural changes, facilitate independent functional mobility, support postural changes for cardio-pulmonary function and accommodate for postural abnormalities, reduce risks for development of skin breakdown and contractures as well as provide for positioning options to reduce risks for aspiration, the following equipment is recommended and is considered medically necessary:
1) Quantum Q-600 Group 3 Power wheelchair with Tru-Comfort Seating and 45 degree power tilt and 150 degree power recline with 8 inch power seat elevation and power elevating leg supports with leg length extension kit to facilitate pressure relief, re-positioning, lower extremity venous flow, accommodation for hamstring tightness, independent postural/positional control to reduce risks for skin breakdown, contractures and aspiration; group 34 batteries(2) and charger
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to provide power to drive and seat functions; flat-free tire inserts to reduce maintenance
concerns; Q Logic joystick with swing-away mount and Multiple Seat Function kit to allow
operation of seat functions thru joystick; 18w x 21h Ergo Back Recline; Tru Comfort Seat 17w x
20d with Ergonomic seat cushion; 4 x 14 adjustable height arm supports; removable head
support to reduce risks for hyper-extension cervical injuries; swing-away lateral trunk supports
to facilitate trunk alignment when seated and to reduce risks for development of trunk
deformity; long thigh supports with dual adjustable mounting bracket to provide for lower
extremity alignment when seated; safety positioning belt.
Thank you for your attention in this matter.
Sincerely,
—————————-, MD
UPIN:
This copy is provided by Active American Mobility and Medical Supply. No restrictions on distribution.
Contact Patrick Boardman 281-495-4400
