SAMPLE LETTER OF MEDICAL NECESSITY FOR E

SAMPLE LETTER OF MEDICAL NECESSITY FOR E.MOTION POWER ASSIST
Letter of Medical Necessity
Date: January ___, _____
Patient Name: x
DOB:
Diagnosis: C5 American Spinal Injury Association (ASIA) A tetraplegia
Equipment Requested: Manual Wheelchair (w/c) with Emotion (Power Assist) Wheels
To Whom It May Concern:
Mr. _______________ is a 24-year-old male who is receiving intensive outpatient physical therapy
services at the ______________ ___________________Center for Spinal Cord Injury in __________.
______ presented with a cervical spinal cord injury following a motor vehicle accident on April 10, 2008.
Prior to his injury, _____was an active, healthy individual. _____currently suffers from C5 ASIA A
tetraplegia, overall weakness of his upper extremities and absent volitional movement of the trunk and
lower extremities, balance impairments, decreased functional mobility (requiring maximum assist for all
bed mobility, transfers, etc.), impaired posture, and decreased sensation.
______ would greatly benefit from a manual wheelchair with Emotion (power assist) wheels to improve his
independence within his home and community (as pt is currently dependently pushed by his mother in a
loaner manual chair). He would also benefit to increase cardiovascular health, encourage continual
improvement of upper extremity strength and range of motion, and enhance his self-esteem. _____ is in
need of a manual wheelchair for exercise and community mobility as he plans to begin college courses on a
nearby campus this spring. The family does not have transportation access for a power w/c and the
home is not accessible to a power w/c (pt has a split-level home with steps to enter and his bedroom is on
the 2nd floor). He also requires a manual w/c in the community for buildings which have stairs. Due to
_____’s tetraplegia, decreased upper extremity muscle strength, decreased endurance, absent trunk and
lower extremity function, and decreased lower extremity sensation, an ultra-light-weight rigid TiLite
ZRA manual w/c with Emotion wheels proves medically necessary.
The following equipment is specified for ________ by the clinical assessment team:
TiLite ZRA Manual Wheelchair: The TiLite ZRA is medically necessary as it is an ultra lightweight
wheelchair, which will allow _____ to negotiate community and household distances with increased
efficiency, energy-conservation, improved negotiation of obstacles, and decreased risk for overuse injuries
of his shoulders. ______ requires custom seat dimensions and strength features that cannot be
accommodated in a standard wheelchair. Because the chair is ultra lightweight, this will also increase the
ease of transportability, making it possible for ______ to transport his chair with decreased assistance. The
chair also provides the best support to allow for proper postural alignment while propelling and when
stationary, which is important for proper respiration, increased efficiency with propelling, and protecting
the spinal joints. In short, the chair will allow _______increased independence and allow him to interact in
his environment and with his family and peers in the most normalized manner.
Power Adaptable Frame: Due to the level of his injury he has weaknesses in arm strength and it is not
adequate to propel a manual wheelchair all day for the distances he needs to cover at home, work, and in
the community. The power adaptable frame will allow for the addition of E-Motion wheels to assist with
independent propulsion.
Seat Back: w/ Blk Alum TiShaft Back Release Bar: supports the J3 back and its hardware; it is required
to allow the back to fold for transport.
5”x1” 2-Pc Alum Front Whl w/Soft Roll: The soft roll caster wheels are necessary to decrease the
vibration under Evan’s lower extremities and buttocks where he has diminished sensation and is at risk for
skin breakdown. The 2 piece billet style wheel will require less maintenance and decrease repair costs.
Airless Inserts: *specific to regular tires: ______ would not be able to adequately maintain pneumatic
tires. Airless inserts require less maintenance and decreases repair cost. Also, prevent Evan from becoming
stranded.
Plastic Coated Handrims Black: *specific to regular tires: The coated handrims will allow Evan to
maintain a better grip on the rims which will improve his propulsion techniques to allow him the safest and
most efficient stroke pattern.
Uni-Lock Wheel LocksPush To Lock and Uni-Lock Wheel Lock Extension: necessary to hold
wheelchair steady during transfers; wheel lock extensions promote independence with securing wheel locks
due to decreased excursion of the trunk and arms to operate and increased lever arm of the wheel lock
which makes operation easier.
Alum. Rigid Removable Side Guards and Swing Away Tubular Armrests 11” to 14”: The side guards
need to be removable to increase the ease and safety of performing lateral transfers. It is important for the
arm rests to be height adjustable to ensure proper alignment of shoulders and neck musculature during
sitting, to minimize the risk of overuse injuries.
Auto Style Release Buckle Seat Belt: properly maintain pelvic positioning when seated in the wheelchair;
allows increased independence with fastening/unfastening and tightening seat belt with limited hand
function.
Calf Strap Velcro Adj Medium: Medically necessary to maintain ______’s feet in proper alignment due
to his decreased sensation and inability to actively position his lower extremities.
User Friendly Rear Flip Up Anti-Tips: These are required to allow for increased stability of the
wheelchair, especially while negotiating environmental obstacles such as ramps and uneven terrain. Antitippers are a necessary safety feature to prevent the chair from tipping backwards from an accidental
wheelie.
Emotion M15 Dual Drive Program Pwr Assist 24” Whls: The Emotion power assist will magnify the
effort that ______ is able to put into propelling the chair. This will allow him to independently propel the
wheelchair for the longer distances he now has to cover at home and in the community (e.g. when attending
college courses on a campus this spring), as well as for future employment. The Duel Drive feature enables
______to change the sensitivity at each wheel, which helps make for more efficient propulsion when one
UE is stronger than the other (as is true in ______’s case). The power assist wheels will decrease the
fatigue of propelling the wheelchair and improve efficiency as well to allow ______to propel the
wheelchair in a reasonable amount of time. This particular combination has been selected over other
wheelchairs as it is felt to be a less expensive alternative while providing the greatest durability. Further, a
manual wheelchair (vs. a power wheelchair, which _______ is unable to get into his home) is better suited
for ______’s available resources and surroundings. *______ has trialed the Emotion wheel system in our
clinic with great results, requiring only supervision-modified independent assist over level surfaces.
Flat Free Inserts/Tires 24”x 1-3/8”: *specific to Emotion wheels: _____ would not be able to adequately
maintain pneumatic tires. Flat free inserts require less maintenance and decreases repair cost. Also, prevent
______ from becoming stranded.
Removable Rubber Hand Rim Covers 24”: *specific to Emotion wheels: The coated handrims will allow
______ to maintain a better grip on the rims which will improve his propulsion techniques to allow him the
safest and most efficient stroke pattern.
18x18 Standard J2 Deep Contour Cushion: this cushion is medically necessary to provide adequate
pressure distribution and provide proper positioning of the lower extremities. *Pt has no issue with wounds
from his current manual (loaner) w/c with J2 Deep Contour cushion (Note: he has a history of 2 wounds in
the past- Stage II on his bottom secondary to hospitalization).
Chest Strap, Elastic, Large: required to provide safe positioning in the w/c over uneven terrain and during
transport.
15” Tall Mid Thoracic Back 18-20 W Posterior: Mid thoracic height with posterior/lateral support and
extended mounting hardware: will provide the patient with appropriate back support given his level of
balance, as well as provide comfort and pressure relief.
Thank you for your prompt attention to this matter and for the opportunity to provide this information to
you so that together we can provide the best mobility and positioning option to best meet ______’s needs.
If you have further questions we may be contacted at the numbers below.
____________________________________
_______________, MD
Faculty, Physician
Center for Spinal Cord Injury
_____________________________
______________, PT, DPT
Staff Physical Therapist
Center for Spinal Cord Injury
ADDRESS
PHONE
FAX
Open as PDF
Similar pages