[DATE] To Whom It May Concern: The following is a letter of medical necessity serving as an addendum to the medical and functional justification in the [PT/OT] Wheelchair Seating and Mobility Evaluation on [DATE] for a power wheelchair and seating system for [CLIENT]. History/diagnosis: [CLIENT] is a [AGE] year-old [MALE/FEMALE] with a primary diagnosis of [DIAGNOSIS]. [CLIENT] also has [PAST MEDICAL HISTORY/SECONDARY DIAGNOSIS] relevant to mobility or seating including: [SKIN BREAKDOWN, INCREASED SPASTICITY, OSTEOPOROSIS, CONSTIPATION, RECURRENT UTI, IMPAIRED RESPIRATORY OR CARDIAC FUNCTION, ROTATOR CUFF IMPAIRMENT, DECREASED STRENGTH, DECREASED SENSATION, DECREASED ACTIVITY TOLERANCE, PAIN, DECLINE IN INDEPENDENCE WITH ACTIVITIES OF DAILY LIVING, etc.] [CLIENT] s height is [HEIGHT] and weight is [WEIGHT]. The number of hours per day the client spends in a wheelchair is [HOURS] hours. The number of hours the client spends alone is [HOURS] hours. Mobility/Function: (Also see Functional Independence Measure (FIM) TM chart attached) [CLIENT] is not a functional ambulator and is not able to propel any type of manual wheelchair safely or efficiently for functional daily use due to decreased strength and mobility secondary to condition described above. [CLIENT] requires the requested power wheelchair with power seat functions specified in order to allow appropriate mobility for activities of daily living in their home and community. [CLIENT] is unable to utilize a POV or basic power wheelchair because of their need for the power seat functions and/or expandable electronics specified. [CLIENT] demonstrated sufficient cognitive and visual ability for appropriate and safe use of the requested power wheelchair and power seating functions specified. [CLIENT] s residence is wheelchair accessible. [CLIENT] s means of transportation is via [PUBLIC BUS/TRAIN, TRANSPORTATION COMPANY, PRIVATE ACCISSIBLE VAN]. [CLIENT] must routinely traverse various uneven terrains in their normal routine, including thresholds, curb cuts, slopes and ramps, [GRASS, GRAVEL, etc.]. [CLIENT] [WORKS/IS A STUDENT/PARENT] and requires the requested power wheelchair and seat functions specified in order to appropriately complete normal routine activities required in this role. [CLIENT] transfers with [AMOUNT OF ASSIST] via [TRANSFER METHOD]. [CLIENT] has increased risk of skin breakdown [AND HISTORY OF SKIN BREAKDOWN?] due to inability to complete effective weight shift. [CLIENT] is dependent on power seat functions for adequate pressure relief. As described in the evaluation, [CLIENT] has severe muscle weakness of [UPPER EXTREMITIES, TRUNK, LOWER EXTREMITIES], and as a result is unable to complete overhead reaching activities for normal activities of daily living.
[CLIENT] requires increased time and [AMOUNT OF ASSISTANCE] assistance in order to complete bathing, grooming, dressing, toileting, and cooking. A new wheelchair is required for the following reasons: [SELECT THOSE THAT APPLY] [CLIENT] does not currently have an appropriate mobility device. [CLIENT] does not own a wheelchair. [CLIENT] s wheelchair is [YEARS] years old and in disrepair, including [LIST ITEMS IN DISREPAIR]. [CLIENT] s wheelchair does not provide required power seat functions necessary for adequate pressure relief and functional independence. [CLIENT] s wheelchair offers insufficient postural support. [CLIENT] s weight has changed from [WEIGHT AT TIME OF CURRENT W/C] to [CURRENT WEIGHT], and their current wheelchair no longer accommodates them adequately. [CLIENT] s medical and functional status has changed, and the client requires the additional power seat functions and features of the requested power wheelchair to meet the needs of [HIS/HER] current condition. [CLIENT] s current wheelchair and seating system do not allow [HIM/HER] to perform [HIS/HER] normal, routine activities of daily living safely and adequately. [CLIENT] s current wheelchair does not provide [HIM/HER] with sufficient mobility and power seat functions for appropriate participation in [WORK, SCHOOL, PARENTING, SOCIAL] activities. [CLIENT] s current wheelchair does not provide [HIM/HER] with sufficient, safe mobility and access to home and community environments and transportation. [CLIENT] s current wheelchair cannot be modified to provide the necessary seating and mobility components required. Recommendations: As a result of this evaluation, other wheelchairs/devices that have been ruled out as not appropriate to meet [CLIENT] s needs include: 1. Lightweight and Ultra lightweight manual wheelchairs because [CLIENT] is unable to functionally propel any manual wheelchair due to decreased strength and endurance, as well as the inability of a manual wheelchair to provide the power seat functions [CLIENT] requires. 2. Group 2 or other Group 3 Power Wheelchairs because these wheelchairs are not able to support the power seat functions [CLIENT] requires. [CHOOSE ALL THAT APPLY AND ENTER ANY ADDITIONAL JUSTIFICATIONS HERE] There is no other reliable and stable front-wheel drive platform currently on the market. Front-wheel drive provides improved maneuverability in [CLIENT] s home and reliable navigation on various terrains/surfaces including ramps. The requested power seating system offers a unique anterior tilt feature that [CLIENT] requires for improved functional independence (see attached FIM TM chart).
The fully independent suspension provided on the Permobil F3 base is medically necessary to absorb jolts/forces that otherwise would contribute to abnormal tone and spasticity resulting in loss of positioning in the seating system as well as potentially unsafe driving and increased pain for client. As a result of this assessment, the following power wheelchair, power seating system, and components are recommended to meet [CLIENT] s needs for safe and appropriate independent mobility and activities of daily living: F3 Power Wheelchair Base, Group 3 (K0861) The F3 is a stable front wheel drive power wheelchair base with programmable electronics and independent suspension, which will allow [CLIENT] to independently and safely operate the wheelchair indoors and on the outdoor terrain, which [CLIENT] encounters in normal activities, including transportation, ramps, and uneven terrain. The F3 will allow [CLIENT] improved navigation over obstacles, such as doorway thresholds, and sufficient navigation around corners/doorways to allow necessary home access. The F3 has the ability to support the necessary power seating system recommended, and is not available on any lesser wheelchair. The Enhanced Steering Performance tracking system, included on the F3, is necessary for adequate, safe drive control when operating the wheelchair with the necessary drive control input device. Corpus Seating System The Corpus Seating System is a modular, ergonomic seating system built to accommodate changes and/or growth. The seat frame depth/width and backrest height is completely adjustable. This allows a custom fit for [CLIENT], and provides accommodation for growth, orthopedic deformities, and significant weight gain or loss. The Corpus seating system accommodates any of the following power seat functions: anterior/posterior tilt, shear reducing recline, power articulating center-mount elevating legrests, and vertical seat elevation. These functions can also easily be added in the future as medical needs change. Batteries (E2359) Two gel sealed batteries are necessary to power the wheelchair. They are maintenance free and are safe for travel on the road or in the air. They are necessary to provide reliable use of the power wheelchair on a single charge and to reduce maintenance, which [CLIENT] is unable to perform. R-net Remote Color Screen Joystick w/ Monojacks The R-net Remote Color Screen Joystick is a proportional upgraded joystick that is separate from the controller box. [CLIENT] has demonstrated safe, independent use of the wheelchair with this input device. The programmable electronics have separate drives and switch options available to safely meet different access, environmental, and terrain needs. The color LCD screen enables users with poor vision to view charge, speed, profiles, etc. by providing improved contrast. R-net also provides for up to eight individually programmable profiles, which allow [CLIENT] to safely drive the chair in various
environments/situations. Mono jack ports allow specialty switches and controls to be used to operate the on/off and modes/profiles function. This is needed because the standard push or toggle buttons are not accessible due to lack of activation strength and limited active range of motion. When using multiple power options, this type of upgraded joystick is needed along with the expandable controller. [RETRACTABLE OR SWING-AWAY] Joystick Mount (E1028) A [RETRACTABLE OR SWING-AWAY] joystick mount allows [CLIENT] to move the joystick out of the way to allow closer access to tables, desks, and counters. It also can facilitate transfers by safely moving out to the side. The joystick can also be moved rearward to allow [CLIENT] improved joystick access in the reclined position. Power Anterior Tilt (K0108) Anterior tilt shifts the entire seating system forward by raising the rear seat to floor height while maintaining front seat to floor height. This powered seat function is necessary to: manage tone/abnormal reflexes, facilitate forward weight shift for transfers and reaching for functional activities, promote attention and vision, and for improved postural control. With up to 30 of anterior tilt, the client is able to get feet properly positioned on the floor for independent/ or minimally assisted sit to stand transfers that would otherwise require the use of a lift system. These exact positions can be saved and recalled with one switch which brings consistency to the daily tasks at hand. Additionally, functional reach of the upper extremity is significantly improved and the client can independently perform activities of daily living such as hygiene/grooming (wash hands, brush teeth, etc.), cooking (providing improved access to the kitchen (cabinets, refrigerator/freezer, microwave, stovetop, sink, etc.) and other daily reaching tasks. Without the use of Anterior tilt, [CLIENT] would need to approach countertops from the side and rotate their trunk to reach items. [CLIENT] does not have the ability to complete reaching/adl tasks from this position due to needing reduced hand function requiring bilateral hand use and impaired trunk mobility. Anterior tilt also provides a lower seat to floor height for improving access under tables/desks. Please refer to the attached FIM TM chart identifying specific functional improvements for [CLIENT] with this feature, making it a medical necessity. Power Adjustable Seat Height (E2300) The power adjustable seat height allows [CLIENT] to raise and lower the seat height independently, increasing vertical reach to promote independence with MRADLs. The power adjustable seat height in combination with the anterior tilt function will allow [CLIENT] to have improved safety and independence with stand-pivot transfers. As [CLIENT] stands from a higher, more forward position, the amount of power and strength required from the lower extremities is significantly reduced. Because of [CLIENT] s strength and endurance limitations, these features are necessary to preserve independent transfer ability. Additionally, the power adjustable seat height provides improved safety and independence with lateral transfers by allowing a level transfer or transfer from a higher to lower surface, which is gravity-assisted.
Power seat elevation also allows [CLIENT] to have eye contact with others and reduces risk of cervical strain and pain, including headaches from poor positioning. Vertical rise also provides psycho-social benefits of being on peer level and speaking eye-to-eye. Additionally, seat elevation allows [CLIENT] to access medicine cabinets and other adult-height surfaces, so they can be used appropriately. Power Tilt and Recline (E1007) Power tilt and recline provide independent adjustment of back and hip angle and have multiple medical and functional benefits for [CLIENT]. [CLIENT] requires the power tilt and recline seat functions because power tilt and recline together: [SELECT THOSE THAT APPLY] 1) Offer maximum pressure re-distribution and postural support to reduce the risk of skin breakdown 2) Offer functional positions for eating, self-care, reaching, and repositioning 3) Provide appropriate positioning for bowel/bladder management (catheterization, urinal, and/or diapering) 4) Recline alone can cause sliding forward and increase posterior pelvic tilt; the addition of power tilt reduces shear when returning to neutral position from recline. Also, tilting before reclining minimizes shearing along the trunk promoting skin health. 5) Provide positioning for blood pressure management (orthostatic hypotension) 6) Provide positioning to control autonomic dysreflexia events 7) Allow multiple changes in position for improved sleeping for rest breaks required due to decreased activity tolerance, eliminating the need for transfers in/out of the chair during the day 8) Promote improved sitting tolerance and independent repositioning for pain management 9) Provide edema control when combined with elevating leg rests 10) Reduce respiratory distress by allowing various supported trunk positions 11) Facilitate exercise in the wheelchair by allowing multiple positions for therapeutic interventions 12) Provide more options for transfers, when needed, with one or two assistants, or independently; especially important for visits to the doctor, dentist, or other health care providers. 13) Provide for normal sexual activity by providing adequate positioning in tilted and reclined position. Additionally, a tilt only system is no appropriate for [CLIENT] because [SELECT THOSE THAT APPLY] 1. A tilt only system does not allow for opening the hip angle. [CLIENT] is at high risk for developing contractures and recline will allow increased ROM of the hip joint. 2. [CLIENT] is unable to tolerate long periods of time without the use of recline without pain. In a tilt only chair, [CLIENT] tolerated only X hours/day before reporting pain. 3. [CLIENT] is unable to complete bowel/bladder management with [LEVEL of ASSIST] in a tilt only chair instead requiring an additional transfer to a flat surface or bed. The use of recline allows
[CLIENT] to complete this ADL while in the wheelchair and decrease fatigue and/or caregiver assistance. 4. [CLIENT] is unable to tolerate sitting at 0 tilt without trunk instability. The use of recline will allow the client to open the back angle of the chair while sitting under standard height tables. Power Articulating Elevating Legrest (K0108) Power articulating elevating legrests allow combined legrest elevation and articulation, which provides [CLIENT] leg extension while elevating. [CLIENT] requires the power articulating elevating leg rests to allow: [SELECT THOSE THAT APPLY] 1. Improved circulation and reduce risk for edema when combined with tilt/recline. 2. Allow change of knee joint position to maintain range of motion and reduce risk for contractures 3. Accommodate for knee range of motion deficits 4. Provide change of position necessary to manage pain 5. Facilitate improved bowel/bladder management by providing proper positioning 6. Provide proper leg positioning to accommodate for wheelchair navigation in various environments: increasing ground clearance to navigate thresholds and slopes; and also allowing the legs to achieve a tight 90 degree position for improved maneuverability required in tight driving conditions Corpus VS Power Articulating Elevating Legrest (K0108) (required for 30 and 45 degrees of anterior tilt) Power articulating elevating legrests allow combined legrest elevation and articulation, as well as weight-bearing and height adjustment from the floor, which provides [CLIENT] leg extension while elevating. [CLIENT] requires the Corpus VS power articulating elevating leg rests to allow: [SELECT THOSE THAT APPLY] 1. Improved circulation and reduce risk for edema when combined with tilt/recline. 2. Allow change of knee joint position to maintain range of motion and reduce risk for contractures 3. Accommodate for knee range of motion deficits 4. Provide change of position necessary to manage pain 5. Facilitate improved bowel/bladder management by providing proper positioning 6. Provide proper leg positioning to accommodate for wheelchair navigation in various environments: increasing ground clearance to navigate thresholds and slopes; and also allowing the legs to achieve a tight 90 degree position for improved maneuverability required in tight driving conditions 7. Allow adjustment of footplate height from floor and weight bearing to provide client with optimal transfer position off of footplates when used in conjunction with the Anterior Tilt Functional Reach/Transfer Packages. 8. Allow weight bearing on footplate to support client s weight while operating wheelchair in anterior tilted position for necessary functional reaching during MRADLs.
Please refer to the attached FIM TM chart identifying specific functional improvements for [CLIENT] with the power post tilt, ant tilt, recline and power elevating/articulating legrest features, further describing their medical necessity. Expandable Controller and Harness (E2377/E2313) The expandable controller is the power module located in the base of the chair that allows the input device to communicate with the drive motors and gear box. The harness is required with the expandable controller and provides the necessary connectors for operation. The expandable controller will allow [CLIENT] to operate their multiple power seat options on the wheelchair base. A non-expandable controller will not allow these features. [CLIENT] also requires an expandable controller to allow the system to accommodate an alternate drive control now or in the future as impairments progress. Alternative drive controls may be required to allow independent, safe operation of the power wheelchair and seat functions, due to decreased strength and motor control. Multiple Seat Function Control Kit (E2311) [CLIENT] requires the Multiple Seat Function Control Kit to allow independent control their of the prescribed power seat functions from the drive control and/or seat function interface. It includes a function selection switch that allows [CLIENT] to select the seat function required and an indicator feature for visual feedback of the selection. ICS Switchbox This seat function interface box will allow [CLIENT] to access 8 momentary switches to control power seat functions separately, without interrupting drive functions through the joystick. This is necessary for incremental adjustments to position, especially when using the drive control to access other functions besides driving, such as computer/phone access. Corpus Ergo Seat (E2605) The Corpus Ergo seat cushion is a positioning cushion necessary for proper support of the pelvis and lower extremities. It provides contour to better align lower extremities for stable positioning and also has varying densities of foam to improve sitting tolerance and reduce the risk of skin breakdown. The upholstered cover is removable and can be washed. Corpus Ergo Back (E2620) The Ergo back is a uniquely designed ergonomic contoured backrest, and is a component of the Corpus seating system. It is required to provide improved sitting tolerance and appropriate trunk support needed due to decreased postural control. Standard planar seating systems are inadequate for appropriate postural support. This backrest, combined with provided lumbar support and lateral wedges increases stability, safety, and improved function. This recommended backrest simulates the contours of
the trunk and provides stability for positioning, as well as reduces the risk of developing spinal deformities. The backrest is customizable with the use of postural supports and is compatible for use with prescribed seat functions. BodyPoint Padded Hip Belt (E0978) The padded hip belt provides safety, proper positioning/stability. The padding protects bony prominences from excessive pressure and promotes improved tolerance and compliance with use. This is particularly important for [CLIENT] while using the anterior tilt function as the pull of gravity shifts when the seat tilts forward. If a proper seat belt is not used, [CLIENT] could fall out of the chair potentially causing injury. Headrest with Adjustable/Removable Hardware (E0955/E1028) A contoured adjustable angle headrest is medically necessary to provide posterior and lateral support to the cervical spine and head. This headrest is used for positioning and head control and is necessary for use with power seat functions prescribed. [OPTIONAL] Lateral Trunk Supports with Swing-Away Hardware (E0956/E1028) Thoracic lateral supports are curved, removable, height adjustable swing-away trunk supports. [CLIENT] requires these supports to provide lateral support to provide additional postural support and positioning to the trunk and spine due to trunk weakness, promoting midline positioning and reducing the risk of leaning to either side, as well as reducing the risk of progression of spinal deformity. Swing-away hardware is necessary for safety with transfers. [OPTIONAL] Thigh Supports with Adjustable/Removable Hardware (E0956/E1028) Thigh supports are multi-position, angle adjustable pads with removable hardware. [CLIENT] requires these pads to properly align the legs due to [WEAKNESS/ABNORMAL TONE] and to provide appropriate lower extremity positioning when in the wheelchair, managing excessive hip abduction/external rotation. Removable hardware is necessary for safety with transfers. (OPTIONAL) Abductor Knee Block with Adjustable/Removable Hardware (E0957/E1028) Abducts the lower extremities to a neutral position while seated. Also provides an anterior support component for reaching using anterior tilt. The adjustable removable hardware is necessary for transfers into/out of the power wheelchair. This recommendation is the most appropriate and cost effective option for meeting the client s functional and medical needs. Please authorize payment for the wheelchair and components. Sincerely, CLINICIAN NAME, TITLE and FACILITY
Functional Independence Measure TM (FIM) Scale: 7 Complete Independence (timely, safely, no device required) 6 Modified Independence (extra time, device required) 5 Supervision (cuing, coaxing, prompting) 4 Minimal Assistance (performs 75% or more of the task) 3 Moderate Assistance (performs 50% to 74% of task) 2 Maximal Assistance (performs 25% to 409% of task) 1 Total Assistance (performs less than 25% of task) Category Mobility - Bed/Chair/Wheelchair Transfers Without Anterior Tilt Comments re: biomechanics/technique (check all that apply) With Anterior Tilt Comments re: biomechanics/technique (check all that apply) Mobility - Toilet Transfers Mobility - Tub or Shower Transfers Self Care Feeding/Cooking Self Care - Grooming Self Care Dressing (upper body) Self Care Dressing (lower body) Total Score (Mobility & Self Care): Summary of FIM Score Data: The results show evidence of improved functional independence with the use of the requested power anterior tilt function that is only available on this specific power wheelchair and seating system.
Functional Independence Measure TM (FIM) Scale: 7 Complete Independence (timely, safely, no device required) 6 Modified Independence (extra time, device required) 5 Supervision (cuing, coaxing, prompting) 4 Minimal Assistance (performs 75% or more of the task) 3 Moderate Assistance (performs 50% to 74% of task) 2 Maximal Assistance (performs 25% to 409% of task) 1 Total Assistance (performs less than 25% of task) Category Mobility - Bed/Chair/Wheelchair Transfers Without Anterior Tilt Comments re: biomechanics/technique (check all that apply) With Anterior Tilt Comments re: biomechanics/technique (check all that apply) Mobility - Toilet Transfers Mobility - Tub or Shower Transfers Self Care Feeding/Cooking Self Care - Grooming Self Care Dressing (upper body) Self Care Dressing (lower body) Total Score (Mobility & Self Care):