![INDEPENDENCE WITH ACTIVITIES OF DAILY LIVING, Etc.] He . - Permobil](/img/54/8-20-15-f5vs-lmn.jpg)
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Client Name:Medical Record #:[DATE]To Whom It May Concern:The following is a letter of medical necessity serving as an addendum to the medical and functionaljustification in the [PT/OT] Wheelchair Seating and Mobility Evaluation on [DATE] for a powerwheelchair 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 seatingincluding: [SKIN BREAKDOWN, INCREASED SPASTICITY, OSTEOPOROSIS, CONSTIPATION, RECURRENTUTI, IMPAIRED RESPIRATORY OR CARDIAC FUNCTION, ROTATOR CUFF IMPAIRMENT, DECREASEDSTRENGTH, DECREASED SENSATION, DECREASED ACTIVITY TOLERANCE, PAIN, DECLINE ININDEPENDENCE WITH ACTIVITIES OF DAILY LIVING, etc.]The [CLIENT]’s height is [HEIGHT] and weight is [WEIGHT].The number of hours per day the client spends in a wheelchair is [HOURS].The number of hours the client spends alone is [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 wheelchairefficiently for functional daily use due to decreased strength and mobility secondary to conditiondescribed above. [CLIENT] requires the requested power wheelchair with power seat functionsspecified in order to allow appropriate mobility for activities of daily living in the home andcommunity. [CLIENT] is unable to utilize a POV or basic power wheelchair because of their need forthe power seat functions specified.[CLIENT] demonstrated sufficient cognitive and visual ability for appropriate and safe use of theF5VS 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, includingthresholds, curb cuts, slopes and ramps, [GRASS, GRAVEL, etc.].[CLIENT WORKS/IS A STUDENT/PARENT] and requires the requested power wheelchair and seatfunctions 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 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 fornormal activities of daily living.[CLIENT] requires increased time and [AMOUNT OF ASSISTANCE] assistance in order to completebathing, grooming, dressing, toileting, and cooking.
Client Name:Medical Record #:Current Wheelchair: [AGE, MAKE/MODEL, DRIVER CONTROL, POWER SEAT FUNCTIONS, ETC.]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] old and in disrepair, including [LIST ITEMS IN DISREPAIR].[CLIENT]’s wheelchair does not provide required power seat functions necessary for adequatepressure relief[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 powerseat functions and features of the F5VS power wheelchair to meet the needs of their currentcondition.[CLIENT]’s current wheelchair and seating system do not allow them to perform their normal,routine activities of daily living adequately.[CLIENT}’s current wheelchair does not provide them with sufficient mobility and power seatfunctions for appropriate participation in [WORK, SCHOOL, PARENTING, SOCIAL] activities.[CLIENT]’s current wheelchair does not provide them with sufficient, safe mobility and access tohome and community environments and transportation.[CLIENT]’s current wheelchair cannot be modified to provide the necessary seating and mobilitycomponents required.Recommendations:As a result of this evaluation, other wheelchairs/devices that have been ruled out as not appropriate tomeet [CLIENT]’s needs include:1. Lightweight and Ultra lightweight manual wheelchairs because [CLIENT] is unable to functionallypropel any manual wheelchair due to decreased strength and endurance, as well as because ofthe absence of required power seat functions on this wheelchair.2. Group 2 or 3 Power Wheelchairs because these wheelchairs are not able to support the powerstanding seat functions required.3. A separate sit-to-stand standing device because the client is unable to independently use orachieve frequency of standing required for health outcomes and functional use. In addition, aseparate standing device does not provide for various methods to achieve standing for properalignment and to manage orthostatic hypotension. Further, the cost of a separate standingdevice along with a power wheelchair with required seat functions is comparable to integratedstanding wheelchair being recommended, and is not considered a least costly equally effectiveoption. The integrated standing power wheelchair creates a much more functional, accessible,and value-added standing means for [CLIENT].
Client Name:Medical Record #:As a result of this assessment, the following power wheelchair, power seating system, and componentsare recommended to meet [CLIENT]’s needs for safe and appropriate independent mobility andactivities of daily living:F5 power wheelchair base, Group 4 (K0884)The F5 is a stable front wheel drive power wheelchair base with programmable electronics andindependent suspension, which will allow [CLIENT] to independently and safely operate the wheelchairindoors and on the outdoor terrain, which [CLIENT] encounters in normal activities, includingtransportation, ramps, and uneven terrain. The F5 will allow [CLIENT] improved navigation overobstacles, such as doorway thresholds, and sufficient navigation around corners/doorways to allownecessary home access. The F5 has the ability to support the necessary power seating systemrecommended, and is not available on any lesser wheelchair.The Enhanced Steering Performance tracking system, included on the F5, is necessary for adequate, safedrive control when operating the wheelchair with the necessary drive control input device.Corpus VS Seating System/Powered Standing (E2301)The VS (Vertical System) is a complete powered seating system with various ways of achieving thestanding position. Standing is accomplished from either a seated, semi-reclined, or fully reclinedposition. In order to do this, full recline, power tilt, elevating leg rests, and vertical seat elevation arerequired. Recline-to-stand allows [CLIENT] to be extended before the weight is transferred onto the feetand mimics standing on a tilt table or supine stander. This method improves standing alignment fromthe head to toe, by reducing buckling at the knees or slipping at the hips. [CLIENT] requires the powerstanding seat functions in their power wheelchair because power standing:1) Allows independent weight bearing multiple times a day, which is essential to reducingosteoporosis, reducing the risk of joint contractures, facilitating normal bone and jointdevelopment2) Reduces depression and other psycho-social issues, enhances interaction with others, andallows [CLIENT] to see eye-to-eye with peers3) Transfers pressure away from the scapulae, sacrum, coccyx, and ischial tuberosities reducing therisk of skin breakdown.4) Assists with digestion, respiration, and bowel/bladder management and appropriate bowel andbladder emptying, facilitating reduction of risk for constipation and UTIs.5) When slowly coming to stand from reclined position, stopping as needed, reduces the risk oforthostatic hypotension, control abnormal or primitive reflexes, and provide spasticitymanagement.6) Provides improved compliance with standing program by having standing feature readilyavailable for active, independent use while client is in the wheelchair.7) Improves access to toilets, sinks, counters, cabinets, and closets while using the stand and drivefeature, improving independence with MRADLs in the normal and appropriate place in thehome8) Improves psychosocial status and participation, allowing [CLIENT] increased access andindependence to perform normal MRADLs and IADLs appropriately.
Client Name:Medical Record #:9) Increases reach for functional access, and making [CLIENT] more productive at [HOME, SCHOOLAND/OR WORK], and reducing overhead reaching and risk of shoulder injury.10) Allows [CLIENT] to stand and drive, providing an effective means of pressure relief to reduce riskof skin breakdown, while making standing more functional and facilitating independentperformance of MRADLs.11) [OTHER CLIENT SPECIFIC FUNCTIONS THAT CLIENT IS ABLE TO DO IN STANDING BUT NOT INSITTING; i.e. RESPIRATORY FUNCTION SITTING VS. STANDING; SPECIFIC HOME/WORK/SCHOOLACTIVITIES AND/OR MRADL FUNCTION AVAILABLE IN STANDING BUT NOT IN SITTING]Batteries (E2363)Two gel sealed batteries are necessary to power the wheelchair. They are maintenance free and are safefor travel on the road or in the air. They are necessary to provide reliable use of the power wheelchairon a single charge and to reduce maintenance which [CLIENT] is unable to perform.R-net Remote Color Screen Joystick w/ MonojacksThe R-net Remote Color Screen Joystick is a proportional upgraded joystick that is separate from thecontroller box. [CLIENT] has demonstrated safe, independent use of the wheelchair with this inputdevice. The programmable electronics have separate drives and switch options available to safely meetdifferent access, environmental, and terrain needs. The color LCD screen enables users with poor visionto view charge, speed, profiles, etc. by providing improved contrast. R-net also provides for up to eightindividually programmable profiles, which allow [CLIENT] to safely drive the chair in variousenvironments/situations. Mono jack ports allow specialty switches and controls to be used to operatethe on/off and modes/profiles function. This is needed because the standard push or toggle buttons arenot accessible due to lack of activation strength and limited active range of motion. When using multiplepower 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 wayto allow closer access to tables, desks, and counters. It also can facilitate transfers by safely moving outto the side. The joystick can also be moved rearward to allow [CLIENT] improved joystick access in thereclined position.Power Adjustable Seat Height (E2300)The power adjustable seat height allows vertical adjustment of the seat height by [CLIENT], whichincreases reach for improved independence with MRADLs. It is also required for the VS standing systemto properly function by providing adequate ground clearance and stability.[CLIENT] will have improved safety and independence with lateral transfers by allowing a level transferor transfer from a higher to lower surface, which is gravity-assisted.OR
Client Name:Medical Record #:[CLIENT] will have improved safety and independence with stand-pivot transfer because the seatelevation feature allows them to stand from a higher seat-to-floor height, reducing the strengthrequired for them to perform a stand-pivot transfer.Power seat elevation also allows [CLIENT] to have eye contact with others and reduces risk of cervicalstrain and pain, including headaches from poor positioning. Vertical rise also provides psycho-socialbenefits of being on peer level and speaking eye-to-eye. Additionally, seat elevation allows [CLIENT] toaccess 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 medicaland functional benefits for [CLIENT]. [CLIENT] requires the power tilt and recline seat functions becausepower tilt and recline together:1) Offer maximum pressure re-distribution and postural support to reduce the risk of skinbreakdown2) Offer functional positions for eating, self-care, reaching, and repositioning3) Provide appropriate positioning for bowel/bladder management (catheterization, urinal, and/ordiapering)4) Recline alone can cause sliding forward and increase posterior pelvic tilt; the addition of powertilt reduces shear when returning to neutral position from recline. Also, tilting before recliningminimizes shearing along the trunk promoting skin health.5) Provide positioning for blood pressure management (orthostatic hypotension)6) Provide positioning to control autonomic dysreflexia events7) Allow multiple changes in position for improved sleeping for rest breaks required due todecreased activity tolerance, eliminating the need for transfers in/out of the chair during theday8) Promote improved sitting tolerance and independent repositioning for pain management9) Provide edema control when combined with elevating leg rests10) Reduce respiratory distress by allowing various supported trunk positions11) Facilitate exercise in the wheelchair by allowing multiple positions for therapeutic interventions12) 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 reclinedposition.Corpus VS Power Articulating Elevating Legrest (K0108)Power articulating elevating legrests allow combined legrest elevation and articulation, as well asweight-bearing and height adjustment from the floor, which provides [CLIENT] leg extension whileelevating. [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 contractures3. Accommodate for knee range of motion deficits
Client Name:Medical Record #:4. Provide change of position necessary to manage pain5. Facilitate improved bowel/bladder management by providing proper positioning6. Provide proper leg positioning to accommodate for wheelchair navigation in variousenvironments: increasing ground clearance to navigate thresholds and slopes; and also allowingthe legs to achieve a tight 90 degree position for improved maneuverability required in tightdriving conditions7. Allow adjustment of footplate height from floor and weight bearing to provide client withoptimal transfer position off of footplates when used in conjunction with the Anterior TiltFunctional Reach/Transfer Packages.8. Allow weight bearing on footplate to support client’s weight while operating wheelchair inanterior tilted position for necessary functional reaching during MRADLs.Please refer to the attached FIMTM chart identifying specific functional improvements for [CLIENT]with the power tilt, recline and power elevating/articulating legrest features, further describing theirmedical necessity.Stand and Drive Leg rest Assembly [K0108]The stand and drive leg rest assembly allows [CLIENT] to drive the wheelchair with the seating system ina standing position, providing improved functional independence and medical benefits of standing asdescribed above. This feature includes additional electronics necessary to allow the wheelchair to bedriven while standing, as well as an additional set of wheels that are attached beneath the footplates,supportingAbductor Knee Block with Adjustable/Removable Hardware: [E0957/E1028][CLIENT] requires the Abductor Knee Block with Adjustable/Removable Hardware to abduct the lowerextremities to a neutral position while seated and to provide an anterior support component forreaching using anterior tilt or standing functions. The adjustable removable hardware is necessary fortransfers into/out of the power wheelchair.Expandable Controller and Harness (E2377/E2313)The expandable controller is the power module located in the base of the chair that allows the inputdevice to communicate with the drive motors and gear box. The harness is required with the expandablecontroller and provides the necessary connectors for operation. The expandable controller will allow[CLIENT] to operate the multiple power seat options on the wheelchair base. A non-expandablecontroller will not allow these features.[CLIENT] also requires an expandable controller to allow the system to accommodate an alternate drivecontrol now or in the future as impairments progress. Alternative drive controls may be required toallow independent, safe operation of the power wheelchair and seat functions, due to decreasedstrength and motor control.
Client Name:Medical Record #:Multiple Seat Function Control Kit (E2311)[CLIENT] requires the Multiple Seat Function Control Kit to allow independent control their of theprescribed power seat functions from the drive control and/or seat function interface. This seat functioninterface box will allow [CLIENT] to access 8 momentary switches to control power seat functionsseparately, without interrupting drive functions through the joystick. This is necessary for incrementaladjustments to position, especially when using the drive control to access other functions besidesdriving, such as [COMPUTER/PHONE/COMMUNICATION DEVICE] access. It includes a function selectionswitch that allows [CLIENT] to select the seat function required and an indicator feature for visualfeedback of the selection.[OPTIONAL] Corpus Ergo Seat (E2605)The Corpus Ergo seat is a positioning cushion made from various densities of foam and has a removable,washable upholstered cover. It is required to provide [CLIENT] with contours to match the normalanatomic contours of the pelvis to provide stability, positioning, and improved sitting tolerance.[OPTIONAL] Corpus Ergo Back (E2620)The Ergo back is a uniquely designed ergonomic contoured backrest and is a component of the Corpusseating system. It is required to provide [CLIENT] with improved sitting tolerance and appropriate trunksupport needed due to decreased postural control. Standard planar seating systems are inadequate forappropriate postural support. This backrest, combined with provided lumbar support and lateral wedgesincreases safety and stability for improved function. This recommended backrest simulates the contoursof the trunk and provides stability for positioning, as well as reduces the risk of developing spinaldeformities. The backrest is customizable with the use of postural supports and is compatible for usewith prescribed seat functions.Stand and Drive Legrest Assembly with [ONE-PIECE OR TWO-PIECE] Footplate (K0108)The stand and drive leg rest assembly allows [CLIENT] to drive the wheelchair with the seating system ina standing position, providing improved functional independence and medical benefits of standing asdescribed above. This feature includes additional electronics necessary to allow the wheelchair to bedriven while standing, as well as an additional set of front anti-tipper wheels that deploy from thewheelchair base during the stand sequence, providing a more stable platform to stand and drive.[OPTIONAL] Separate Flip-Up FootplatesThe separate flip-up footplates for the VS are required to provide [CLIENT] with individual adjustability(angle and height) to accommodate a leg length discrepancy or asymmetrical ankle range of motion.[CLIENT] requires the separate flip-up footplates to allow the footplates to fold completely out of theway for safe performance of stand pivot transfers.[OPTIONAL] Body Point Padded Hip Belt (E0978)[CLIENT] requires the padded hip belt to provide safety, stability and proper positioning, as well asimproved seating and standing tolerance and compliance, protection of boney prominences, and toaccommodate for abnormal muscle tone.
Client Name:Medical Record #:Chest Support with Adjustable Removable Hardware [K0108/E1028][CLIENT] requires the chest support and mounting hardware to provide additional safety and stability,particularly necessary when standing, as well as to allow chest bar to be removed for transfers.Headrest with Adjustable/Removable Hardware (E0955/E1028)A contoured adjustable angle headrest is medically necessary to provide [CLIENT] with posterior andlateral support to the cervical spine and head. This headrest is used for positioning and head control andis 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 lateral supports to provide additional postural support and positioning to the trunk and spinedue to trunk weakness, promoting midline positioning and reducing the risk of leaning to either side, aswell as reducing the risk of progression of spinal deformity. Swing-away hardware is necessary for safetywith transfers.[OPTIONAL] Thigh Supports with Adjustable/Removable Hardware (E0956/E1028)Thigh supports are multi-position, angle adjustable pads with removable hardware. [CLIENT] requiresthese pads to properly align the legs due to abnormal tone and to provide appropriate lower extremitypositioning when in the wheelchair. Removable hardware is necessary for safety with transfers.[OPTIONAL] Upper Extremity Support with Adjustable/Removable Hardware (E0950/E1028)An Upper Extremity Support tray is necessary to provide [CLIENT] with appropriate support for upperextremities, not available with conventional armrests, as well as a functional work surface. It can alsoassist in promoting thoracic extension for improved function and respiratory capacity. The necessaryhardware to mount the upper extremity support to the wheelchair frame is angle adjustable andremovable for improved vision and to allow transfers.[OPTIONAL] R-Net Bluetooth iDevice Module (K0108)The R-Net Bluetooth iDevice Module allows [CLIENT] to utilize their wheelchair input device to operatean iPhone, iPad, or iPod. This feature allows [CLIENT] to make phone calls, send text messages, andemails, as well as access applications on their iDevices. This is necessary for safety allowing [CLIENT] tocall for help during an emergency, as well as obtaining normal access to communication tools thatprovides connectivity to the outside world.[OPTIONAL] R-Net BT Mouse Module (K0108)The R-Net Blue Tooth Mouse Module provides a method for [CLIENT] to access computer mouseemulation through the wheelchair controls because [CLIENT] is unable to use a standard or adaptedcomputer mouse and keyboard due to impaired motor control. This is required for normal, appropriate[HOUSEHOLD, SCHOOL, WORK] and other activities that require use of a computer.
Client Name:Medical Record #:This recommendation is the most appropriate and cost effective option for meeting the client’sfunctional and medical needs. Please authorize payment for the wheelchair and components.Sincerely,CLINICIAN NAME, TITLEFACILITY
Client Name:Medical Record #:Functional Independence MeasureTM (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%CategoryWithoutStandingMobility - Bed/Chair/Wheelchair TransfersMobility - Toilet TransfersComments re:biomechanics/technique(check all that apply) Unsafe technique riskingpain/injury/skin breakdown Device required: Other (specify): Mobility - Tub or Shower Transfers Self Care – Feeding/Cooking Self Care - Grooming Self Care – Dressing (upper body) Self Care – Dressing (lower body) With StandingComments re:biomechanics/technique(check all that apply) Unsafe technique riskingpain/injury/skin breakdown Device required: Other (specify):Unsafe technique riskingpain/injury/skin breakdownDevice required:Other (specify): Unsafe technique riskingpain/injury/skin breakdownDevice required:Other (specify): Unsafe technique riskingpain/injury/skin breakdownDevice required:Other (specify): Unsafe technique riskingpain/injury/skin breakdownDevice required:Other (specify): Unsafe technique riskingpain/injury/skin breakdownDevice required:Other (specify): Unsafe technique riskingpain/injury/skin breakdownDevice required:Other (specify): Unsafe technique riskingpain/injury/skin breakdownDevice required:Other (specify):Unsafe technique riskingpain/injury/skin breakdownDevice required:Other (specify):Unsafe technique riskingpain/injury/skin breakdownDevice required:Other (specify):Unsafe technique riskingpain/injury/skin breakdownDevice required:Other (specify):Unsafe technique riskingpain/injury/skin breakdownDevice required:Other (specify):Unsafe technique riskingpain/injury/skin breakdownDevice required:Other (specify):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 standingfunction that is only available on this specific power wheelchair and seating system.
Client Name:Medical Record #:
UTI, IMPAIRED RESPIRATORY OR CARDIAC FUNCTION, ROTATOR CUFF IMPAIRMENT, DECREASED STRENGTH, DECREASED SENSATION, DECREASED ACTIVITY TOLERANCE, PAIN, DECLINE IN . [HOME, SCHOOL AND/OR WORK], and reducing overhead reaching and risk of shoulder injury. 10) Allows [CLIENT] to stand and drive, providing an effective means of pressure relief to .
