Letter of Medical Necessity #1
RE: John Doe Date of Birth: 11-18-87
DX: Microcephaly/CP Funding: MA
Parent: Phone:
Address: MN Date: 01-12-99
General Medical Condition:
____is an 11 year old male referred to Rehab Center by Dr._____. ____has a birth history significant for partial deletion of the long arm of the 1st chromosome. _____ also had a left brachial plexus injury, which affected his diaphragm. ____ was admitted to the NICU for 4 1/2 weeks. He has history of seizures and apnea. His seizures are controlled by medication at this time. Medications include Benadryl and Depakote. Past surgical history includes derotation osteotomies 4 years ago, hardware removal 3 years ago and abdominal surgery 2 years ago. He also has history of metatarsal fracture 1 1/2 years ago. Per mother, ____s cognition is 24
months. He enjoys music. He has a hearing impairment and wears bilateral hearing aids. ___ received Botox injections to bilateral hamstrings on 8-10-98 and began physical therapy in the pool 9-98. Primary focus is to assist ____ out of his flexed position.
Since____s hip surgery, he has been unable to tolerate LE weightbearing and has developed contractures in his hips, knee and ankles in a flexor synergy. ____has made gains in the pool with LE extension and is beginning to weightbear with assistance. Because ____ has grown to significant size, 4’8″ and 110 lbs., it is unreasonable to work on standing without the assist of a standing frame. He
requires maximal assist of one or two people to maintain stance for greater than a brief transfer secondary to limited extension and strength in weightbearing on land. ____ requires maximal assist to transfer. He needs maximal assistance for transitions into/out of his chair. ____does not ambulate at this time. Per parent, he did take a few steps with assistance for balance prior to his hip
surgery. ____ can sit independently, his primary form of mobility is a modified bunny hop for short distances ( 3-5-feet) . ____ spends a majority of his day in his wheelchair.
Current Program:
At this time ____ does not have a stander available to him at school or home. Secondary to his contractures, ____ will not tolerate a
standard standing frame that requires knee extension along with dorsiflexion at his ankles. But more importantly, it would be
unsafe and impractical to try to lift and position him into a standing frame (prone or supine). _____s mother does his transfers
independently at home and needs a support/standing frame that ___ can be positioned in with one person. ____ also needs a type
of stander that can be slowly moved into extension as he is able to tolerate. ____ will be in his stander daily with parent or PCA.
With increased tolerance of weightbearing and LE extension, ____ will in the future be able to assist with stand pivot transfers into
and out of his wheelchair, toilet and bed.
Equipment Trial:
___ underwent a trial with the EasyStand Evolv which he tolerated well. He demonstrated his tolerance in one session at Rehab
Center and then the stander was utilized at his school for a week which was a positive experience for ____ as well as his therapist
and teacher. He was able to stand for 25 minutes the first session. He was assisted to a sitting position in the EasyStand from his
wheelchair by his mother. ____ was then slowly and gently elevated into weightbearing position with slow increase in hip and knee
extension. He was able to tolerate -25 degrees of knee extension and -30 degrees of hip extension. ___ was able to tolerate more
extension in the stander for a prolonged period of time versus when 2 or more caregivers are attempting to support his stance with -
45 to 50 degrees of knee and hip extension. The other plus for this stander is that ___ will be able to utilize this stander into adulthood.
Recommended Equipment:
Recommended at this time is the EasyStand Evolv with the 19” contoured back and a seatbelt. It has four seat depth adjustments for growth and chest strap for additional support and safety. If _____ does not address his hip and knee contractures through weightbearing and prolonged stretch now that he is making some progress towards extension, his future will hold more surgery and equipment for transfers. (Hoyer) ____ will benefit from addressing his contractures and limited weightbearing now to ensure his functional independence and participation in transfers in the future.
Jane Doe , PT Dr. John Doe
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
Special thanks to Altimate Medical for this letter.
