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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 5/23/22 for a wheelchair and seating system for [CLIENT].
• [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.]
• 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].
[CLIENT] is not a functional ambulator and is not able to propel any lessor type of manual wheelchair efficiently for functional daily use due to decreased strength and mobility secondary to condition described above. [CLIENT] transfers with [AMOUNT OF ASSIST] via [TRANSFER METHOD]. [CLIENT] completes pressure reliefs with [AMOUNT OF ASSIST] via [METHOD].
• [CLIENT] is independent, safe and willing to use the ultra-lightweight wheelchair specified
• [CLIENT] requires the features on this wheelchair to allow maximal independence and safety, as well as appropriate mobility for activities of daily living in the home and community.
• [CLIENT] is unable to utilize a high strength lightweight wheelchair because of their need for the seat dimensions and/or frame dimensions specified, which are not available on any high strength lightweight wheelchair
• [CLIENT] requires an adjustable axle position, also not available on any high strength lightweight wheelchair, in order to:
◦ Improve access to wheels
◦ Promote optimal biomechanical alignment for efficient propulsion and prevention of repetitive stress injuries (RSI)
◦ Enable adjustment of front/rear seat-to-floor heights for proper position/center of gravity due to decreased trunk control, spasticity, and/or to accommodate for client height
• [CLIENT] demonstrated sufficient strength, balance, as well as cognitive and visual ability, for appropriate and safe use of the ultra-lightweight wheelchair 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] is a highly active person, and their ability to continue to be a highly active person is optimized in the ultra-lightweight wheelchair specified.
• [CLIENT WORKS/IS A STUDENT/PARENT] and requires the requested ultra-lightweight wheelchair and features specified in order to appropriately complete normal routine activities required in this role.
• As described in the evaluation, [CLIENT] has severe muscle weakness of [UPPER EXTREMITIES, TRUNK, LOWER EXTREMITIES], and as a result is unable to propel any other wheelchair for normal activities of daily living.
• As described in the evaluation, [CLIENT] presents with: decreased endurance/fatigue AND/OR history of UE RSI or rotator cuff injury
◦ due to the nature of their diagnosis, over-exertion is contra-indicated, and client must utilize an ultra-lightweight wheelchair [WITH POWER-ASSIST]
◦ in order to accomplish daily MRADLS and mobility without exacerbating their condition.
• As described in the evaluation, [CLIENT] reports pain limited sitting tolerance AND/OR increased spasticity when rolling over bumps, thresholds, and obstacles.
• [CLIENT] requires increased time and [AMOUNT OF ASSISTANCE] assistance in order to complete bathing, grooming, dressing, toileting, and cooking. The ultra-lightweight wheelchair and features recommended allow client to complete MRADLs with maximal independence and safety
◦ [Consider FIM, perceived exertion, or time measurement of client performing activity with/without the recommended wheelchair to illustrate objective functional improvement with the wheelchair.]
Current Wheelchair: [AGE, MAKE/MODEL, SERIAL NUMBER, DISREPAIR ISSUES, PROBLEMS WITH PROPULSION and/or POSTION IN THE CHAIR]
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 offers insufficient postural support.
• [CLIENT]'s weight has changed from [WEIGHT WHEN CURRENT W/C PROVIDED] 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 features of the ultra-lightweight wheelchair specified to meet the needs of their current condition.
• [CLIENT]'s current wheelchair and seating system do not allow them to perform their normal, routine activities of daily living adequately OR within a reasonable amount of time
• [CLIENT]'s current wheelchair does not provide them with sufficient mobility and postural support for appropriate participation in [WORK, SCHOOL, PARENTING, SOCIAL] activities.
• [CLIENT]'s current wheelchair does not provide them 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.
As a result of this evaluation, other wheelchairs/devices that have been ruled out as not appropriate to meet [CLIENT]'s needs include:
1. Any ambulatory device because [CLIENT] is not a safe, functional ambulator for all daily mobility/MRADLs.
2. Lightweight and high strength lightweight manual wheelchairs because [CLIENT] is unable to functionally propel these types of manual wheelchairs due to decreased strength and endurance, as well as because of the absence of the required adjustable axle plate and/or seat/frame dimensions.
Ultra-lightweight manual wheelchair:
[CLIENT] requires the TiLite ZR and features specified to allow independent and safe push-rim biomechanics and positioning for appropriate mobility indoors and on the outdoor terrain, which [CLIENT] encounters in normal activities, including transportation, ramps, and uneven terrain. Individually configured seat/frame dimensions, not available on any lesser wheelchair, are critical for necessary positioning and function in the wheelchair as follows:
• The seat width and seat sling depth dimensions specified are required to accommodate for client's anatomical measurements and to facilitate appropriate positioning, postural support and pressure relief when seated in the wheelchair.
• The seat width, rear seat-to-floor height, and center of gravity specified, together provide optimal axle position for propulsion - individually measured and configured for optimal push-rim biomechanics for [CLIENT].
• [CLIENT] also requires Front and Rear Seat-to-Floor Height dimensions specified in order to:
◦ Accommodate for [CLIENT]'s height/leg measurements
◦ Assist with proper position and balance in the wheelchair
• The Back angle specified facilitates client position and balance in wheelchair, as well as necessary wheel access for propulsion.
◦ And accommodates limitations in lower extremity range-of-motion.
• Footrest Width/Taper specified is required to appropriately fit front frame width to [CLIENT]'s dimensions and promote ability for the client to get as close to objects as possible for transfers and reaching during MRADLs.
• Front frame angle/style specified facilitates [CLIENT]'s lower extremity positioning and allows optimal ability to get close to objects for transfers and MRADLs.
◦ And accommodates limitations in lower extremity range-of-motion.
• Camber specified facilitates optimal wheelchair accessibility and wheel position for propulsion and balance.
• Titanium Frame:
◦ A Titanium Frame is required to provide optimal performance and durability to accommodate for [CLIENT]'s highly active lifestyle, including reducing the chair weight to as light as possible for propulsion and for independent transfers into a vehicle for transport; increasing the frame strength for optimal durability; and optimizing the shock absorption/vibration dampening to increase sitting tolerance by decreasing their effects on spasticity and pain.
◦ Due to [CLIENT]'s highly active lifestyle, they have a history of breaking non-titanium frames/components, making titanium's added strength and durability critical for long term, safe wheelchair performance.
• The Foot Plate Style specified is required in order to provide proper, safe lower extremity positioning
◦ And accommodate for spasticity and/or ROM deficit
• Front Caster Size/Style specified is required for optimal client maneuverability, durability, and rollability in their every-day environment.
• The rear wheels specified are required for optimal propulsion biomechanics, durability, and to keep weight of wheelchair as light as possible for both propulsion and transport.
• The rear tires specified are required for optimal wheelchair performance and durability.
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.
CLINICIAN NAME, TITLE