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Example Letter of Medical Neccessitty for Sleepsafe Bed and Wheelchair

Wednesday, October 19th, 2011

2 EXAMPLES of LETTER OF MEDICAL NECESSITY

The following example letter of medical necessity and advice are only intended to assist you in writing your own letter to aid in securing funding for medical equipment. It is in no way implied that if you use this example you will be granted funding for medical equipment. Our only intention is to share information that we have gathered in the past and used by other clients.

The funding agencies that would be in charge of compensation for such medical items, such as your insurance company or a private philanthropic organization, almost always demand a letter of medical necessity from a therapist (physical, occupational, or otherwise) or from a physician to prove your claim that your child’s medical equipment was necessary to his successful treatment. The claim or appeal will be likely be refused if you do not include a letter of medical necessity which includes a detailed explanation of the condition or disability that makes the equipment a necessity for your loved one.

It is possible that your particular physician may not fully be acquainted with the rules of your insurance company which will affect whether or not you are reimbursed for your child’s medical equipment. (Each insurance company or state may have slightly different rules.) To be on the safe side, educate yourself on the rules so that you can be a better advocate for your family. You should become familiar with the bare minimum of information that needs to be included in a letter of medical necessity. Otherwise, the letter may contain insufficient information, which may lead to the funding agency denying your claim.

The following is an example of a thorough and professional letter of medical necessity taken from Dr. Freeman Miller’s Cerebral Palsy: A Complete Guide for Care giving. If you prefer, you can take a copy of this letter to the physician who is writing your child’s letter of medical necessity, and ask that he or she adhere to the example letter below.

“To Whom It May Concern (or, better, to a specific employee of the funding agency):

John Smith is a 5-year-old male with a primary diagnosis of cerebral palsy. He was seen at the Seating Clinic at the John Doe Institute in Anywhere, USA, on June 23, 2007, for the prescription of a bed system to meet his resting needs.

John presents with the following: generally decreased tone in upper and lower extremities, and fair head and trunk control. He is dependent in transfers and mobility. He is cognitively severely delayed. He is incontinent in bowel/bladder. He has frequent respiratory complications and is subject to bronchitis and pneumonia, and he receives chest therapy. He occasionally aspirates, he has increased skin sensitivity, and he has seizures, but they’re generally under control with his medication. He must have safe sleeping environment to eliminate the danger of falls and entrapment with appropriate positioning to provide safety and support, and to facilitate safe sleeping, breathing and feeding.

His current bed is a ___________ that is three years old. It no longer meets his bedding needs because he has outgrown it, and it poses safety concerns because_____________________.

The goals for John’s sleeping and resting is to provide a safe sleeping environment where falls and entrapment no longer pose a threat for harm and to foster a comfortable rest, maintain posture, provide comfort, and enhance function. Upon evaluation, _____________________ has recommended that the following equipment be prescribed for John:

(Be very specific in the bed model, size, and specific safety features)

the following example is for a wheel chair…rewrite this section to detail all of the specific features of the recommended bed system….for example…the Sleep Safe 2 Plus model is prescribed because it offers 22 inches of safety rail height protection above the mattress, eliminating the risk of a fall when he is in a sitting position. The “plus” model frame is prescribed because he is dependant on tube feedings and his head must be elevated during this time….etc)

The ____________________(is prescribed because it is a manual wheelchair for total positioning, and because he is dependent in mobility. The tilt is needed because he is hypotonic in head and trunk. He also has difficulty breathing, and it will help aid in feeding. It will help with low endurance and pressure relief, and it will control seizure reaction. The adjustable height arms are needed to support tray at right height, for upper body support and balance, and for ease of transfers. The I-back will bring side supports close to trunk, but insert will fit the full width of the wheelchair. The laterals will encourage midline trunk position, compensate for lack of trunk control, provide safety, and contour around trunk for better control. The chest harness is needed for safety in transport by providing anterior support, preventing forward flexion, and retracting shoulders. The headrest is needed for poor head control due to low tone, active flexion of head, posterior lateral support, safety in transfers, and to facilitate breathing. The clear tray is needed for functional surface for schoolwork, stimulation, upper arm and trunk support, inability to access tables, computer, and a base for augmentative communication devices. The shoe holders are needed to control increased extension or spasms in lower extremities, excessive internal rotation, and to prevent aggressive behavior for safety. The anti-tippers are needed for safety.

Should you have any questions regarding these recommendations, please do not hesitate to call me at (555) 555-5555. We hope that you will be able to accommodate these needs in an expedient manner. Thank you for your cooperation and assistance in this manner.

Sincerely,

John Doe

Be sure to take note of when your child’s letter was sent to the funding agency, and if three or four weeks pass without word from them, you might want to call the agency to inquire about the status of your claim. Always keep a record of when you call and with whom you speak to, and always try to remain calm and collected when dealing with the insurance company. If, however, you are unable to obtain a straightforward response as to when your claim will be processed, do not hesitate to enlist the help of your physician.

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

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