Posts Tagged ‘medical need’

Sample Justification Letter of Medical Neccessitty for ALS Group 3 Power Wheelchair and Accessories

Wednesday, October 19th, 2011


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.


—————————-, MD

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

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.

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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.