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ZR | Summary |
LMN Template
7/23/26
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 7/23/26 for a 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.]
• 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:
[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.
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. 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.
• V-Front End specified is required for safe foot positioning, stable balance and stability. The footplate width that is appropriate is not available in a standard front end option.
◦ [CLIENT] is getting skin breakdown from the frame taper and the v-front allows for improved pressure distribution.
◦ The width of the client's feet is ______, which requires a specific footplate width of ______, which cannot be accommodated with a standard taper. Without the appropriate footplate width, the lower extremities cannot be safely stabilized on the footplate, would be at risk for falling off the footplate and getting caught in the casters or touching the ground.
◦ V-Front End 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.
◦ The V-Front end is necessary to minimize risk of pressure at the lower extremities by providing straight tubing at the front end of the chair that is angled in toward the footplate. This is necessary for skin protection as well as lower extremity positioning.
◦ The V-Front end is required when using the required front seat taper option.
• 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.
• Custom Frame Depth specified is required to provide optimal fit of wheelchair frame to client for improved stability and roll-ability of the chair; to reduce rolling resistance and assist with prevention of RSI; to improve energy conservation and reduce fatigue and pain; to allow improved mobility over carpets, grass, thresholds and other uneven terrain routinely encountered.
• 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.
◦ Titanium wheelchair components (Seat Back Type, Footrest Type, & Fork Stem) are required 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 strength of the parts specified for optimal durability; and optimizing shock absorption/vibration dampening effects.
◦ 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.
• Carbon Fiber wheelchair components (Back Support) are required to make the wheelchair as light as possible to facilitate propulsion and independent transfers into vehicle for transport.
• The Foot Plate Style specified is required in order to provide proper, safe lower extremity positioning
◦ And accommodate for spasticity and/or ROM deficit
• [CLIENT] requires the ROHO® Agility backrest specified in order to provide necessary postural support, positioning and balance, as well as to provide sufficient pressure relief, especially for boney prominences, when seated in the wheelchair. The back rest specified is also necessary to manage their postural asymmetry due to their diagnosis.
◦ The Agility Carbon back will allow [CLIENT] to keep the overall wheelchair and seating system as light as possible to facilitate propulsion and independent transfers into vehicle for transport.
• 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.
◦ [CLIENT] requires high pressure tire and low profile treaded tire specified in order to reduce rolling resistance during propulsion to facilitate longer coast times, resulting in fewer push strokes during the day. Fewer push strokes during the day mitigate risk for repetitive stress injuries and upper extremity pain, which [CLIENT] is at risk for. Higher rolling resistance and greater number of push strokes is associated with increased incidence of repetitive stress injury and upper extremity pain.
• Wheel locks specified are required to provide [CLIENT] with the ability to independently and safely secure wheels for transfers or MRADLs.
• Seat Upholstery specified is necessary to provide proper postural support and assist with positioning in the chair by accommodating frame style required
• [CLIENT] requires the ROHO® QUADTRO SELECT® cushion specified in order to provide appropriate postural support, pressure relief, and pressure distribution when sitting in the wheelchair due to: (SELECT ALL THAT APPLY.)
◦ Increased risk for skin breakdown
◦ Impaired sensation
◦ History of pressure injury
◦ Presence of current pressure injury
◦ Inability to complete functional weight shift
◦ Need to provide client with a means to ensure their cushion is at the recommended inflation for optimal pressure relief/distribution.
◦ Need to manage postural asymmetry due to their diagnosis
• An adjustable skin protection and positioning cushion is necessary to adjust cushion to pressure relief and postural support required now, as well as to adapt to anticipated client changes during the life of the cushion.
• Side guards are required to maintain cushion in a centered position when seated in the wheelchair, to assist with lower extremity positioning, and to prevent clothing from becoming entangled in the wheels.
Permobil SmartDrive:
[CLIENT] requires the Permobil SmartDrive power assist device to utilize with their manual wheelchair.
The SmartDrive power assist is very lightweight and can be easily installed and removed from the wheelchair for charging and transportation. In addition, the SmartDrive power assist does not compromise chair configuration, so [CLIENT] can maintain a stable sitting posture and efficient propulsion technique when in their manual wheelchair. The SmartDrive power assist device also frees up [CLIENT]'s upper extremities for function.
• A Power wheelchair does not meet the functional needs of [CLIENT] due to:
[SELECT THOSE THAT APPLY]
◦ lack of transportation
◦ sufficient upper extremity strength to self-propel short distances
◦ independent weight shifts
◦ transfer status or technique
◦ does not fit in the client's home
◦ does not meet seating and positioning needs
◦ cannot be utilized for specific MRADLs [LIST WHAT MRADLS APPLY]
[CLIENT] has completed trial of SmartDrive power assist and was able and willing to use it appropriately and safely. [CLIENT] is an excellent candidate for the SmartDrive power assist device; without this device, [CLIENT] will be less independent in functional mobility and require additional assistance for MRADLs and mobility, as well as be at an increased risk for repetitive stress injury. [CLIENT] is able to start and stop independently using the recommended control device, as well as steer the chair and brake appropriately.
FOR MEDICARE: [CLIENT] has utilized a manual wheelchair for greater than one year and is currently unable to be effective with manual wheelchair propulsion without a power assist device due to the impairments and functional limitations listed below.
The Wheelchair propulsion test indicated that [CLIENT] was able to propel 10 m in ______ seconds without the SmartDrive, compared to 10 m in _______ seconds with the SmartDrive, indicating an improvement in functional manual propulsion efficiency.
• [CLIENT] requires the use of a SmartDrive power assist due to the following impairments of body functions and structures:
[SELECT THOSE THAT APPLY]
◦ impaired upper extremity strength
◦ impaired grip strength
◦ impaired postural strength
◦ upper extremity repetitive strain injury
◦ pain and/or pain with propulsion
◦ decreased activity tolerance
◦ progressive weakness and fatigue during the day
◦ medical condition exacerbated by excessive exertion
◦ ataxia
◦ impaired coordination
◦ impaired motor control
◦ spasticity
[CLIENT] requires increased time and [AMOUNT OF ASSISTANCE] assistance in order to complete MRADLs. The use of the SmartDrive with their current wheelchair and features recommended allows them to complete MRADLs with maximal independence and safety.
[Consider FIM, perceived exertion, or time measurement of client performing activity with/without the SmartDrive and recommended w/c to illustrate objective functional improvement. Consider use of the visual (pain) analogue scale (VAS) with and without use of SmartDrive.]
• [CLIENT] requires the use of SmartDrive power assist to accomplish the following MRADLs in a safe, efficient, timely manner including:
[SELECT THOSE THAT APPLY]
◦ bathing
◦ grooming
◦ dressing
◦ toileting
◦ meal preparation
◦ taking out the garbage
◦ doing laundry
◦ childcare
◦ housecleaning
◦ moving from room to room
◦ navigating small thresholds
◦ ramp negotiation, including to enter/exit the home
◦ propelling their manual wheelchair on carpet or through surface transitions throughout the home
With the use of the SmartDrive power assist, [CLIENT] is also able to complete MRADLs in a timely and efficient manner, as demonstrated by ____ [PROVIDE OBJECTIVE MEASURE, ex: to take laundry from the laundry room to the bedroom, it took 7 minutes and 25 pushes and 5 times to reposition the laundry basket; however, with the SmartDrive, it took 2 minutes, 4 pushes and no requirement to reposition the laundry basket].
[SELECT APPLICABLE JUSTIFICATIONS BELOW]
• The SmartDrive Power Assist also helps [CLIENT] maintain a better posture/position in the wheelchair during propulsion. [CLIENT] must reposition themselves ___ times/hour without SmartDrive with Switch Controls, in comparison to ___ times/hour with the SmartDrive with switch control. The increased stress and strain that occurs with self-propulsion often results in postural asymmetries and loss of upright positioning for [CLIENT], including:
[SELECT THOSE THAT APPLY]
◦ posterior pelvic tilt
◦ thoracic kyphosis
◦ pelvic obliquity
◦ scoliosis
◦ forward head
◦ hip abduction
◦ loss of foot positioning on footplate
• In order for [CLIENT] to achieve their goals of participation, they require the use of SmartDrive power assist to:
[SELECT THOSE THAT APPLY]
◦ return to/safely & effectively participate work
◦ return to/safely & effectively participate school
◦ volunteer in the community
◦ achieving life roles
◦ attend medical appointments or doctor visits
◦ grocery or household shopping
◦ decreasing caregiver assistance and/or allow safe caregiver assistance
◦ driving a vehicle and loading their chair into the vehicle
◦ attend religious services or family activities
• [CLIENT] has demonstrated the ability to utilize the SmartDrive to complete the following tasks:
[SELECT THOSE THAT APPLY]
◦ propel independently on even terrain
◦ propel independently on uneven terrain
◦ propel independently on ramp of _____% grade
◦ [CLIENT] required only ____active pushes to move _____ft/m in comparison to ______active pushes to move _____ft/m without the SmartDrive power assist
◦ negotiated ____" threshold
◦ carried [OBJECT]
SpeedControl Dial
[CLIENT] has demonstrated the ability to use the SpeedControl Dial to engage the SmartDrive, to stop the SmartDrive, and to control the individually programmed speed appropriately.
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
FACILITY