Posts Tagged ‘Quantum’

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

Wednesday, October 19th, 2011

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

Page 2/————————

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

SCI/Quadriplegia C7; Osteoarthritis; Sample Letter of Medical Neccessity for Quantum Power Chair and Seating

Wednesday, October 19th, 2011

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).
Page 2/——————

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:

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

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

Wednesday, October 19th, 2011

Date:

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.

Sincerely,

————————–, MD
UPIN:

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

Newsletter

Twitter