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 1 b 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 2 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%$73') Form 11.01.2013 3 Wheeled Mobility Letter of Medical Necessity Form *INDIVIDUAL'S NAME: John Brown *ID NUMBER: 000000000 19. Functional Skills ACTIVITY LEVEL OF INDEPENDENCE DME USED TO ADDRESS FUNCTIONAL TASK Bathing Supervision Provide number from DME list on page 3: Dressing Independent Provide number from DME list on page 3: Grooming Independent Provide number from DME list on page 3: Eating Independent Provide number from DME list on page 3: Toileting Independent Provide number from DME list on page 3: In-home mobility Independent Provide number from DME list on page 3: 20. Orthosis(es)/Prosthesis(es): NA / None ITEM LEFT/RIGHT/BOTH 18b Left Ineffective None N/A N/A None N/A N/A None N/A N/A None N/A N/A sister supervises transfers to ensure safety independent; c/o severe pain independent independent independent; c/o severe pain 18A EFFECTIVENESS Below Knee Prosthesis(es) HUSKY Health COMMMENTS/FUNCTIONAL CONSIDERATIONS FOR REQUESTED DME independent; c/o severe pain COMMENTS/IF INEFFECTIVE, PLEASE EXPLAIN unable to use due to extreme pain in left hip when ambulating all distances, even < 5 feet Wheeled Mobility LMN$&52%$73') Form 11.01.2013 4 b 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 5 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 6 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 7 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 8 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 9 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 11 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 12 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 [email protected] 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 13
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