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