Insert Date

Any Insurance Company
123 Any Street
Any City, Any State 12345

Re: Patient's Name
DOB: Patient's DOB
ID #: Insurance ID # in the case of private insurance and /or public assistance.

Address: Patient’s Address

Parent/ Guardian’s Name:

Parent/ Guardian’s Phone Number:

Example: Tariq is a 12 year old boy who was diagnosed with Autism Spectrum Disorder (ASD) at 20 months old. He has generalized low muscle tone and decreased strength compared to typically developing peers. Posture is significant for increased lumbar lordosis, scapular protraction/ winging, and forward head due to core muscle weakness. Gait and running patterns are poorly coordinated. Tariq has significant motor planning difficulties with decreased motor memory causing it to be a time and labor intensive process to learn and retain new motor skills. He has difficulty with complex coordinated patterns of movement (throwing and catching a ball, skipping, hopping). Balance, righting, and equilibrium reactions are weaker than what is considered typical for a boy Tariq’s age, but they are functional. Tariq can navigate the middle school environment safely. He can walk up and down stairs with one hand on the railing for support engaging in a reciprocal foot pattern but requires increased time. Tariq also struggles with handwriting issues and scissor skills. Sensory issues are significant. Tariq is hypersensitive to most loud unexpected sounds and bright visual stimulus. Behavioral disorganization can result from abrupt unexpected changes in his environment, but he manages well in familiar environments where others are aware of his challenges and sensitive to his needs. He is generally independent in strategies to regulate his behavior in the school environment but frequently struggles with behavioral issues at home. Regulation of sleep patterns is an issue. Tariq sleeps in a Beds by George Haven Series Bed to ensure his safety. Tariq is enrolled in accelerated learning programs in the academic areas of math and science.  

Example: Tariq receives educational support and accommodations in the school environment per his 504 plan. His parents pay privately to consult with a Physical Therapist and Occupational Therapist regarding issues of motor learning and sensory issues. Tariq participates in athletic programs in the community that are sensitive and accommodating to participants with special needs. He has benefitted greatly from hippotherapy over the past 5 years. Tariq also meets regularly with an educational psychologist.  

Current Functional Problems:

• Tariq struggles to participate in physical education classes at school.
• Tariq requires increased time and effort to learn new motor skills.
• Tariq struggles with behavioral issues which can compromise his safety on long car rides.
• Tariq displays significant frustration regarding his fine motor skills (writing, scissor skills, areas of creative expression that require fine motor skills).
• Behavioral issues can be significantly disruptive to family life.

Long Term Treatment Goals:

• Tariq will navigate school and home environments safely with increasing levels of confidence and independence.
• Tariq will independently engage in sensory regulatory strategies.
• Tariq will participate in activities that improve his overall strength and endurance and promote confidence and self-esteem.
• Tariq will engage in appropriate compensatory strategies in areas where fine motor skills restrict function.
• Improve self-regulation of behavior in the home environment.

Treatment Strategies:

• PT and OT consult services to offer guidance in strategies to address progressive strengthening/ endurance program and overall motor learning.
• OT consult services to offer recommendations regarding sensory regulation.
• PT and OT consult services to identify durable medical equipment and assistive technology to ensure Tariq’s safety and maximize independent function in all environments.
• Educational Psychologist services to support social emotional development.

Example: As Tariq’s consulting physical therapist I am requesting funding authorization for a Special Tomato Soft Touch Booster Car Seat Size Large, Dark Gray. Tariq is 58.7 in. tall and weighs 88 lbs. Although he is of adequate size and weight to not require a booster seat, low muscle tone, decreased strength and endurance and sensory issues cause car rides to be especially challenging for Tariq and his family and at times unsafe. In attempts to help Tariq be more comfortable and safer in the car, a Special Tomato Soft Touch sitter was loaned and trialed over a 3 week period. Immediate improvements in Tariq’s ability to tolerate car rides was observed and sustained. He spontaneously offered “This is good!” in response to the tactile experience of sitting on the Soft Touch Contoured Booster Car Seat. The fact that the seat is contoured and offers lateral support allowed Tariq to rest comfortably and safely in the seat and stopped his attempts to lie down in the back seat of the car amongst dangerously entangled seat belts. The contouring of the seat offered structured spatial boundaries that Tariq benefitted from. He also benefitted from having the seat described as being like the seats used by astronauts during space travel! Because he was comfortable, Tariq spent his time travelling in the car listening to music and watching funny Instagram videos on his iPhone. Both Tariq and Tariq’s mom (driving the car) expressed their overall assessment as “Much Better!”. Tariq’s ability to maintain an upright, relaxed, and comfortable posture within the seat belt properly positioned for safety and restraint was consistent. Tolerance for the length of the car ride dramatically improved. The fact that this seat is also approved for air travel was attractive to this family. If approved for funding of the Special Tomato Soft Touch Booster Car Seat, the family has also considered purchasing the Floor Sitter Base for Tyrek to use when he is sitting on the floor with his siblings and playing video games. When his posture is properly supported Tyrek’s fine motor skills improve and his skill level rises more closely to that of his siblings.

Itemization of the Special Tomato® Soft-Touch® Booster Car Seat:

Include only those product features that will be applied for.

Item

Description of Medical Necessity

Floor Sitter Base- Tilt-in-space positioning allows for fully upright sitting or sitting tilted back as far as 25 degrees and anywhere in between. This allows the user to engage postural muscles to varying degrees as tolerated and as activity dictates. With the Floor Sitter Wedge Base, the user can be positioned sitting on the floor where peers and siblings typically play.

Stationary Base - The Stationary Base allows children to be close to the floor without caregivers having to transfer them all the way down to the floor. The Stationary Base is equipped with furniture glides to protect floors.

Mobile Base- The Mobile Base is the same as the Stationary Base, with the addition of 3 in. locking urethane casters to allow the child to be moved room to room or to different parts of the classroom without picking up the child.