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Wheeled Mobility Letter of Medical Necessity Form
*INDIVIDUAL'S NAME: John Brown
*ID NUMBER: 000000000
INDIVIDUAL’S INFORMATION AND BACKGROUND
*1.
2.
Date of Birth (mm/dd/yyyy): 00/00/000
Date of Evaluation (mm/dd/yyyy): 01/10/2014
Address Line 1: 134 Ashford Center Road
*3.
Address Line 2:
City:
Ashford
State: CT
Zip Code:
06278
Evaluation Zip Code:
06269
Evaluation Location Address L1: Special Needs Rehabilitation Center
*4.
Evaluation Location Address L 2: 123 Main Street
Evaluation City:
5.
6.
*7.
Height:
Storrs
Evaluation State: CT
5 FT
10 IN
Name
Professionals Present:
DME Provider Evaluator:
165 LBS
Weight:
Credentials
Agency
Steven Blessing
DPT
Special Needs Rehab Center
Mary Jones
MS, OTR
Special Needs Rehab Center
Fabulosa Atprofessional
ATP
ABC Mobility Corporation
Not required for SNF/ICF Residents
8.
* 9.
*10.
Caregiver/Family:
Laura Brown, sister
Prescribing Physician:
John Martin, MD
Physician Phone Number:
Physician Agency:
*11.
Physician Address:
Physician City:
Present During Evaluation?
YES
203-000-0000
Special Needs Rehabilitation Center
1234 Health Street
Storrs
Physician State:
CT
Physician Zip Code: 06269
Size
a. Primary Reason
for Evaluation: Initial Wheeled Mobility Device
12.
*13.
b. Primary Issues
Relating to DME
(explain in 12c):
Does not address current medical needs
Does not address current functional needs
See #23
c. Other Pertinent Information; i.e.,
additional information from 12b,
rationale for replacement vs.
modification, repair history, other
information regarding request:
General Description of
DME Recommendation:
HUSKY Health
Permobil M 300 power chair with power seat elevator/recline/legrests and
seating components
Wheeled Mobility LMNA&52%$73')Form 11.01.2013
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Wheeled Mobility Letter of Medical Necessity Form
INDIVIDUAL’S NAME:
John Brown
14.
ID NUMBER:
000000000
DIAGNOSIS(ES), INCLUDING RECENT SURGERIES AND DATES OF SURGERIES
Traumatic Left Above Knee amputation & Spinal cord injury, T-10 incomplete level, as result of
MVA (05/2008)
Bilateral rotator cuff syndrome assc w/ repetitive motion/use
Spinal fusion (10/2010)
How will the person’s
anticipated medical
changes be
accommodated in the
requested Wheeled
Mobility Device?
16. Caretaker Support:
16a.
16b.
YES, see 14a
YES, see 14a
Explain recent change Bilateral upper extremity rotator cuff syndrome associated with repetitive motion/use using
in medical condition loftstrand crutches which lead to Dx of Osteoarthritis in shoulders
and/or other relevant
information including
symptoms, treatments,
interventions and
medications:
■
15.
NO
N/A
Osteoarthritis in Bilateral hips and shoulders (diagnosed 12/2012)
14a.
RECENT CHANGE IN
MEDICAL STATUS
The requested Wheeled Mobility Device can be modified to meet anticipated medical needs
Other:
This power chair's electronics can accept the addition of other power features if
needed in the future. The seating components can be modified or added if/when the
patient's medical needs change.
The individual has 24 Hour Care.
Caretaker Support Hours per Day: N/A
Amount of Time Alone per Day:
Relationship/Role:
N/A
17. Additional Information:
This person is alone 24 hours per day. His sister, who does not live with him, provides ADL support if needed.
HUSKY Health
Wheeled Mobility LMNA&52%$73') Form 11.01.2013
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Wheeled Mobility Letter of Medical Necessity Form
INDIVIDUAL’S NAME:
John Brown
ID NUMBER:
000000000
*18. List all Current/Previous DME:
DME TYPE, INCLUDING
MANUFACTURER
AND MODEL
18A. Type/Mfg/Model:
Loftstrand crutches
DATE OF
PURCHASE
(MM/YYYY)
(MM/YY)
ENVIRONMENTS
WHERE USED
(SELECT ALL THAT
APPLY)
IS DME
CURRENTLY
BEING
USED?
■
Yes
09/12
Home
does not address
chronic pain in L hip;
ambulation endurance
is limited to <20 feet
Work
School
Guardian
■
IF INEFFECTIVE,
PROVIDE REASON
Community
SKILL LEVEL
(CHECK ALL THAT APPLY)
Independent
WNL endurance and distance
■
Dependent
SNF/ICF
Comments, including
special features (e.g.,
specialty seating
components or
electronics):
Ownership:
18B. Type/Mfg/Model:
Transfer Tub Bench
Below normal endurance and distance
Other:
Mr. Brown would prefer to be independent using left lower extremity prosthesis; however, his hip pain is
intolerable.
✔
Personally Owned
(MM/YY)
10/13
■
Home
Other
Yes
to enable safe transfers
for hygiene tasks and
for back support
Work
School
Drive Medical
■
Independent
WNL endurance and distance
Below normal endurance and distance
Community
Dependent
SNF/ICF
Other:
Comments, including
special features (e.g.,
specialty seating
components or
electronics):
Ownership:
18C. Type/Mfg/Model:
Personally Owned
(MM/YY)
None
Home
Other
Independent
N/A
Work
WNL endurance and distance
School
Below normal endurance and distance
Community
Dependent
SNF/ICF
Other:
Comments, including
special features (e.g.,
specialty seating
components or
electronics):
Ownership:
18D. Type/Mfg/Model:
Personally Owned
(MM/YY)
None
Home
Other
Independent
N/A
Work
WNL endurance and distance
School
Below normal endurance and distance
Community
Dependent
SNF/ICF
Other:
Comments, including
special features (e.g.,
specialty seating
components or
electronics):
Ownership:
HUSKY Health
Personally Owned
Other
Wheeled Mobility LMNA&52%$73') Form 11.01.2013
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Wheeled Mobility Letter of Medical Necessity Form
*INDIVIDUAL'S NAME: John Brown
*ID NUMBER:
000000000
19. Functional Skills
ACTIVITY
LEVEL OF INDEPENDENCE
DME USED TO ADDRESS
FUNCTIONAL TASK
Bathing
Supervision
Provide number from
DME list on page 3:
Dressing
Independent
Provide number from
DME list on page 3:
Grooming
Independent
Provide number from
DME list on page 3:
Eating
Independent
Provide number from
DME list on page 3:
Toileting
Independent
Provide number from
DME list on page 3:
In-home
mobility
Independent
Provide number from
DME list on page 3:
20. Orthosis(es)/Prosthesis(es):
NA / None
ITEM
LEFT/RIGHT/BOTH
18b
Left
Ineffective
None
N/A
N/A
None
N/A
N/A
None
N/A
N/A
None
N/A
N/A
sister supervises transfers to ensure safety
independent; c/o severe pain
independent
independent
independent; c/o severe pain
18A
EFFECTIVENESS
Below Knee Prosthesis(es)
HUSKY Health
COMMMENTS/FUNCTIONAL CONSIDERATIONS
FOR REQUESTED DME
independent; c/o severe pain
COMMENTS/IF INEFFECTIVE, PLEASE EXPLAIN
unable to use due to extreme pain in left hip when
ambulating all distances, even < 5 feet
Wheeled Mobility LMN$&52%$73') Form 11.01.2013
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Wheeled Mobility Letter of Medical Necessity Form
INDIVIDUAL’S NAME:
John Brown
21. Transfer skills:
Independent for all transfers
000000000
ID NUMBER:
FROM
Dependent for all transfers
TO
METHOD
Varied transfer skills; see completed table
LEVEL OF INDEPENDENCE
EQUIPMENT
N/A
N/A
Stand pivot
Independent
N/A
N/A
N/A
Stand pivot
Independent
N/A
N/A
N/A
Stand pivot
Independent
N/A
N/A
N/A
Stand pivot
Independent
N/A
22. Ambulation skills:
SURFACE
Non-ambulatory on all surfaces
AMBULATION STATUS
SPEED
Ambulatory on all surfaces
DISTANCE
Varied ambulation skills; see completed table
ENDURANCE
BALANCE
SPECIFY
AMBULATION
AIDE
Carpet:
Ambulatory
Slow
< 10 Feet
< 5 Minutes
Moderate impairment
crutches
Smooth:
Ambulatory
Slow
10 - 30 Feet
5 - 10 Minutes
Moderate impairment
crutches
Varied Terrain:
Non-Ambulatory
N/A
N/A
N/A
N/A
N/A
Stairs:
Non-Ambulatory
N/A
N/A
N/A
N/A
N/A
23. Describe conditions which impact person’s ability to ambulate and/or transfer safely, independently, and in a timely
manner; e.g., weakness, cardiovascular/respiratory compromise, range of motion deficits, imbalance, tone, cognitive
deficits, coordination, sensory deficits:
Pain increases with prolonged weight bearing into lower extremities and lower back. Pain in lower back also increases with
prolonged sitting in one position. Global weakness, imbalance, and loss of LE ROM, multiple arthritic conditions and Left AK
amputation significantly inhibit ambulation endurance and safety. Recent falls noted in bathroom when transferring to
bathtub.
24. Postural Control, Muscle Strength, and tone
STRENGTH
(+) / (-)
TONE
Fair (3)
(+)
WNL
Right Upper
Extremity:
Good (4)
(+)
WNL
Left Upper Extremity:
Good (4)
(+)
WNL
Right Lower
Extremity:
Good (4)
(+)
WNL
Trunk:
Left Lower Extremity:
Head/neck:
Other
WNL
WNL (5)
WNL
HUSKY Health
COMMENTS
Above knee amputation
Wheeled Mobility LMNA&52%$73') Form 11.01.2013
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Wheeled Mobility Letter of Medical Necessity Form
INDIVIDUAL’S NAME:
John Brown
ID NUMBER:
000000000
25. Postural Alignment of trunk, pelvis, neck, and lower extremities
POSTURAL ALIGNMENT
FIXED VS. FLEXIBLE
Alignment WNL
Flexible
Pelvis/Hips:
Even
Flexible
Head/Neck:
Normal
Flexible
Leg Length:
Even
Flexible
Ankles/Foot/Toes:
Even
Flexible
Trunk/Spine:
COMMENTS, INCLUDING QUANTITATIVE DATA
Other pertinent
information:
26. Coordination, Motor Control, and Balance
ACTIVITY
Sitting Balance (Static):
FUNCTIONAL SKILLS
ACTIVITY
Standing (Static): Unsteady
Steady, safe
Describe: due to left above knee amputation and pain
Describe:
Upper Extremity Gross
Motor Control:
COMMENTS/FUNCTIONAL SKILLS
Upper Extremity Fine
Functional
Motor Control:
Functional
Describe:
Describe:
27. Range of Motion (Optional: attach data)
AREA AFFECTED
RANGE OF MOTION LIMITATIONS RELATIVE TO SEATING
COMMENTS/QUALIFYING INFORMATION
Right Upper Extremity: limited above 85 degrees in all planes above shoulders
Left Upper Extremity:
limited above 85 degrees in all planes above shoulders
Right Lower Extremity:
Left Lower Extremity:
lacks ~ 25 degrees hip flexion
not formally evaluated
Head/Neck:
28. Pain (Ref: www.painmed.org/SOPResources/ClinicalTools/government-websites/).
LOCATION
INTENSITY
FREQUENCY
DURATION
Unable to determine if person is experiencing pain
COMMENTS/QUALIFYING INFORMATION;
RELATIONSHIP TO POSITIONING
Left Lower Extremity
9
Chronic
constant
Left hip Osteoarthritis; noted tenderness in Left
sacroiliac joint; intermittent Phantom pain syndrome
B Upper Extremities
8
Chronic
constant
Bilateral upper extremity osteoarthritis in shoulders
Lower Back
7
Daily
1 - 3 hours
severe pain in lower back T7 and below; also noted
discomfort in gluteal and piriformis musculature
HUSKY Health
Wheeled Mobility LMNA&52%$73') Form 11.01.2013
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Wheeled Mobility Letter of Medical Necessity Form
*ID NUMBER: 000000000
*INDIVIDUAL'S NAME: John Brown
29. Skin integrity (optional: attach Braden Scale http://www.bradenscale.com/images/bradenscale.pdf)
CURRENT SKIN INTEGRITY STATUS
Intact
HISTORY OF SKIN INTEGRITY
RISK FACTORS
Intact
None
If Impaired, date(s) of onset:
If Impaired, date(s) of onset:
If Impaired, stage:
If Impaired, stage:
If Impaired, location(s):
If Impaired, location(s):
Ability to use pressure reducing methods:
Impaired Nutritional Status
Bony Prominences
Fecal and/or Urinary Incontinence
Self-positioning
Circulatory Compromise
Pressure Methods Comments:
■
Immobility
Sensory Deficits
Aged Skin
General Comments:
If Sensory Deficits, indicate:
30. Cardiovascular, Pulmonary, Vascular, Bowel and Bladder status
CONDITION
Cardiac Status:
Normal
Pulmonary Status:
Normal
Vascular Status:
Normal
If Impaired, Edema Grade Level:
Bowel and Bladder Status:
N/A
Normal
Catheterization:
No
Suppository use:
No
HUSKY Health
CLINICAL OBSERVATIONS / REFERENCE TO DIAGNOSIS
Wheeled Mobility LMNA&52%$73') Form 11.01.2013
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b
Wheeled Mobility Letter of Medical Necessity Form
*INDIVIDUAL'S NAME: John Brown
*ID NUMBER:
000000000
31. List the primary medical and functional objectives for the recommended wheeled mobility device, including how this
will impact the individual’s ADL independence:
- to reduce pain and increase mobility related ADL tasks (MRADL) participation, including mobility outside the home
- to allow him to work part time
- to address safety risks in daily mobility related ADL tasks, especially for hygiene tasks
- to impeded worsening of osteoarthritic changes
32. Describe the effectiveness of the trial simulation(s), including the person’s ability to utilize the recommended
wheeled mobility device system within their customary environment(s), i.e., hallways, bedroom, bathroom, ramp,
varied terrain. The following criteria/information must be included reflecting the person’s cognitive, visual,
safety, and fine and gross motor skills: (1) strength (2) endurance (3) range of motion (4) balance (5) risk factors
considered, e.g., repetitive motion (6) location of trials (7) duration/frequency of trial(s) (8) ability to use controls;
e.g., directionality, start/stop, special features; i.e., tilt, recline, power leg rests, seat elevator, power assist, one
arm drive, tiller (9) need for additional training or caretaker assistance for drive controls. Indicate Dependent if
applicable.
John was trialed with two mid-wheel drive power chairs (Quantum Q6 Edge, Permobil M300). He was effective controlling
both power chair controls. John was able to navigate his home, including bedroom and bathroom entrances and the ramp
entering the 4 steps into the house. His cognitive status is WNL and he displays adequate safety sense/judgment to use
the recommended power chair in the home and in the community. He will require training for use of the recline system
which need to be synchronized with the power elevating legrests. He was also trialed in his backyard, as per his request,
and he was able to manage the varied terrain, including the need to traverse over 3" obstacles. He will require an
adaptation to charge the batteries since this is currently difficult for him to reach. It is anticipated that he will be a 'heavy'
power chair user since this will be his primary mobility method.
33. Are there anticipated changes in the individual’s customary environments with the next 1-2 years? If so, how was
this taken into consideration for the requested wheeled mobility device?
No
Yes, please explain:
Mr. Brown is hoping to return to work yet this cannot be confirmed. Mr. Brown previously worked as a bookkeeper which
is a desk job and should not pose an accessibility problem.
34. Explain/describe other medical approaches, functional strategies, other DME and/or alternative treatment(s), which
were considered and ruled out in lieu of using a wheeled mobility device.
John can no longer use his Left above knee prosthesis for other than short distances due to progression of his
osteoarthritis. PT Tx & pain medication was ineffective to address chronic pain. The Roll About Knee Walker did not relieve
hip/lower back pain. Physician does not recommend total hip replacement due to hip osteoarthritis. John was trialed with
ultralightweight manual wheelchair; however, this was ineffective due to shoulder pain upon manual propulsion. A
medical scooter was trialed but he was unable to control the tiller without shoulder pain or transfer independently. He
was able to operate an upright power chair but it did not address his chronic hip & lower back pain.
HUSKY Health
Wheeled Mobility LMNA&52%$73')Form 11.01.2013
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Wheeled Mobility Letter of Medical Necessity Form
*INDIVIDUAL'S NAME: John Brown
*ID NUMBER: 000000000
35. For residents of Skilled Nursing Facilities:
a. What is the length of time
per day that the wheeled
mobility device will be used?
If this request is for a replacement wheeled mobility device under Sec. 17-134d-46 Customized Wheelchairs In
Nursing Facilities Regulation, attach a copy of the current positioning program (required).
b. Describe the positioning program used
to address the individual’s needs,
including the monitoring program.
c. What is the person’s
out of bed tolerance?
36. Training to be provided to who/where/by whom for wheeled mobility use:
CLINICAL OBSERVATIONS / REFERENCE TO DIAGNOSIS
Other, please explain
If other, please explain:
He will require training for general power chair, use of controls/modes, and for effective use of the recline system as
paired with the power elevating legrests.
37. Comments (include e. g., Continued from #xx):
HUSKY Health
Wheeled Mobility LMNA&52%$73')Form 11.01.2013
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Wheeled Mobility Letter of Medical Necessity Form
INDIVIDUAL’S NAME:
John Brown
ID NUMBER:
000000000
Based on the clinical assessment & consideration of various Wheeled Mobility options, the following is suggested to
address this person’s medical needs:
38.
*
Description of DME component:
This list can be pre-populated by
the DME Provider. Postural
components can be combined
with hardware; e.g., lateral
trunk pads with swing-away
mounting hardware; phenolic
upper extremity support with
channel locks and strap.
39. Medical Rationale: Pre-populated, generic, and general rationales and definitions
will not be accepted. Information must include:

Document the rationale for requested base or component for this specific
person, as correlated with the documented clinical information. Reference
comparisons and simulations; e.g., “Based upon trials of the seat cushions xx, yy,
and zz, the zz cushion was chosen because….” Note: Only the essential
components require comparison of various options, as related to the person’s
medical condition.

If appropriate, include reason why a standard component would not address the
person’s medical needs.
*
Technical rationales can be written by the DME provider which should be
designated with an asterisk. Include the reason the component is needed, as
compared to less complex alternatives and correlated with necessary functional
or technical outcomes.
a.
*Permobil M300 power chair, center
wheel drive
-chosen as compared to Quantum Q6 Edge power chair since the design of the back more
effectively addressed the patient's pain without needing to use a custom back support
-shock/suspension system more effective to reduce spinal/pelvic impact than Quantum
power chair
*-will accommodate 300 pounds and suitable for indoor/outdoor use
b.
*22NF batteries
-*necessary to operate all power chair functions
c.
*power recline 150 degrees
-to enable independent change in back angle in relation to the seat to relieve back and hip
pain, as paired with power elevating legrests
-will allow change in position to impede loss of skin integrity
d.
*center mount power
elevating/articulation legrests
-will allow John to independently elongate his LE musculature to relieve back and hip pain,
as paired with power recline mechanism
e.
*multiple seat function control kit
*specialty electronics required for operation of two or more seat control functions through
the power chair electronics
f.
*Verilite Evolution seat cushion
-standard Corpus seating found to be inadequate for pressure relief
-Various seat cushions were trialed. An air cushion found most effective to manage
buttocks pressure when compared with a gel-based seat cushion (Jay3 gel), gel/air
combination (Jay3 ROHO insert) and High Profile ROHO which was unstable.
g.
*Permobil Corpus Back Support
-offers adequate postural support and height to accommodate John's 23" back height
HUSKY Health
Wheeled Mobility LMN ACROBAT PDF Form 11.01.2013
10
Wheeled Mobility Letter of Medical Necessity Form
*INDIVIDUAL'S NAME: John Brown
h.
i.
j.
*ID NUMBER: 000000000
*Swing-up height adjustable
armrests
4" wide x 12" long armrest provide a wide base of support for his shoulders as per bilateral
shoulder osteoarthritis while being able to swing-up for ADL access/clearance
*Right retractable joystick
allows ADL access/clearance for tables and sink and to enable safe stand-pivot transfers
*Permobil 6" headrest with
mounting hardware
-for head support when using recline feature
-beneficial to decrease shoulder discomfort
k.
l.
m.
n.
o.
p.
q.
HUSKY Health
Wheeled Mobility LMN ACROBAT PDF Form 11.01.2013
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b
Wheeled Mobility Letter of Medical Necessity Form
*INDIVIDUAL'S NAME: John Brown
*ID NUMBER: 000000000
r.
s.
t.
u.
v.
w.
x.
y.
z.
aa.
HUSKY Health
Wheeled Mobility LMN ACROBAT PDF Form 11.01.2013
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b
Wheeled Mobility Letter of Medical Necessity Form
INDIVIDUAL’S NAME:
John Brown
ID NUMBER:
000000000
bb.
cc.
dd.
I certify that I wrote this report and I am the Licensed Occupational and/or Physical Therapist identified below. I have included my
credentials, affiliated agency, address, and contact information. My signature affirms that I personally wrote each section of this
report, except where an asterisk is designated, based upon my own clinical knowledge, training and evaluation of the person’s
medical condition.
Name: Steven Blessing
Credentials:
DPT
CT License #:
2581
Agency: Special Needs Rehabilitation Center
Address L1:
123 Main Street
Address L2:
City: Storrs
Phone Number:
203-000-0000
State:
Fax Number:
CT
Zip Code:
203-000-0000
Email
Address:
06269
sblessing@snrc.org
Electronic Signature Agreement. By clicking “I agree” and electronically signing below, you certify that: (1) you and the agency/facility in
which you are employed agree to follow and are in compliance with the Connecticut Department of Social Services Conditions for DSS
Acceptance of Electronic Signatures (“Electronic Signature Policy”) and (2) your electronic signature below complies with the Electronic
Signature Policy. A handwritten signature is required for all other practitioners.
✔
Signature:
Date (mm/dd/yyyy):
01/12/2014
Physician’s Signature: By signing below, I have reviewed and concur with the above evaluation:
Physician Agency:
Physician NPI:
Special Needs Rehabilitation Center
123123123
Electronic Signature Agreement. By clicking “I agree” and electronically signing below, you certify that: (1) you and the agency/facility in
which you are employed agree to follow and are in compliance with the Connecticut Department of Social Services Conditions for DSS
Acceptance of Electronic Signatures (“Electronic Signature Policy”) and (2) your electronic signature below complies with the Electronic
Signature Policy. A handwritten signature is required for all other practitioners.
✔
Signature:
HUSKY Health
Date (mm/dd/yyyy):
Wheeled Mobility LMN ACROBAT PDF Form 11.01.2013
01/14/201
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