Date:
To: Medicare
Re: ———————-
DOB: 00-00-0000
HICN: ———————
Diagnosis/Problems: SCI/Quadriplegia C7; Osteoarthritis
Subject: prescription for power wheelchair and seating equipment
To Whom It may Concern,
——————— is a 45 year old male patient of mine who suffered a C7 level spinal cord injury secondary to a MVA over 30 years ago. As a result he is quadriplegic, unable to ambulate, and dependent upon a wheelchair for mobility. Without a wheelchair he would be bed and/or room confined. Currently, he is using a manual wheelchair that was loaned to him by a friend. It is a lightweight frame but is significant disrepair. —————- is having increasing difficulty with propelling any type of manual wheelchair up/down ramps or across unfinished/uneven surfaces secondary to debilitation of shoulder function and loss of strength/endurance as a result of multiple decades of manual wheelchair propulsion.
————- lives in a rural setting in a mobile home that requires him to traverse rough/unfinished terrain daily and to be able to manage propelling himself up/down a 30-40 foot ramp daily to enter/exit his home. He lives on a farm with other family members living in homes that are adjacent to his so he must propel himself in/out of his home several times a day. ————— is reporting increasing shoulder and back pain with manual wheelchair propulsion within his home and on level surfaces as well. He reports taking 40mg of Vicodin per day for pain. He recently severed the skin on several fingers of his right hand and is unable to propel himself up/down his ramp secondary to pain in his hand. It is recommended that he be provided a power wheelchair that will meet his functional mobility needs and support his daily independence.
Due to the nature of his diagnosis, the following postural abnormalities and physical problems will need to be addressed in his wheelchair and seating equipment:
1) Moderate right pelvic obliquity(fixed) with secondary right scoliotic curvature of spine resulting in increased risks for skin breakdown on right IT’s/buttocks and/or increased risks for development of fixed contractures in spine/trunk.
2) Mild kyphotic curvature/deformity in upper thoracic spine.
3) Fair bilateral shoulder strength with poor bilateral wrist extension/flexion, MCP and IP flexion/extension impaired bilaterally. Poor endurance with available upper extremity movement(s).
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4) Moderate to High risk for skin breakdown secondary to constant sitting, inability to perform adequate pressure relief in current equipment, loss of sensation below mid level of back, and a history of pressure breakdown(10 years ago).
In order to provide for safe supported sitting, facilitate independent functional mobility, accommodate for postural/physical abnormalities and reduce risks for secondary complications such as skin breakdown, the following equipment is recommended and is considered medically necessary:
1) Quantum 600 power wheelchair base with Tru-Balance power seat tilt is recommended to facilitate independent functional mobility and to provide for independent weight-shifting/pressure relief to reduce risks for skin breakdown. A PG 70 amp joystick with thru controller operation of drive/seat functions is recommended; 14 inch flat-free tires are needed since —————- cannot independently maintain tire pressure/repair flats; 50 amp gel batteries are required for drive/seat function power; Solution cushion is recommended for needed pressure relief when not tilted to reduce risks for skin breakdown; high mount foot platform to facilitate foot support when in tilted positions; solid curved seat back with Stealth head support to reduce risks for hyper-extension injuries/fatigue when in tilted postures; 2-post flip back arm supports with desk length pads;
Thank you for your consideration in this matter.
Sincerely,
———————————, MD
UPIN:
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Contact Patrick Boardman 281-495-4400
