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Sample Letter of Medical Necessity for Special Tomato® Soft-Touch® Booster Car Seat

The Sample Letter of Necessity below includes guidance as well as examples you can tailor to your own needs. 

Tip: Contact the beneficiary's insurance company and ask them to provide you with their definitions of medical necessity. Be sure to include all components in your letter while using the samples below as a general guideline.

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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:

Medical History: Briefly/ succinctly stated including diagnosis with onset date, comorbidities, and surgeries.

Current Medical Status and Functional Status: Explain the beneficiary's condition with emphasis on functional ability and impairments. Make the reader “see” this child. Include all durable medical equipment this child is already using.

 

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.  

 

Current Program of Intervention: List specific functional problems. List long term treatment goals. Describe what is being done to help the child achieve these goals.

 

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.

 

Rationale for Treatment with Therapeutic Equipment: Describe how the piece of equipment will medically benefit the child. How will the equipment reduce the need for other services? What might be the medical impact if this piece of equipment is denied. Identify the aspects of the child’s life that the equipment will be of assistance and how will it improve the child’s level of function in the home. Identify how the equipment will enable treatment goals to be met. Be specific.

 

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.

 

Itemized Description of Medical Necessity for Special Tomato Soft Touch Booster Car Seat (ALL Special Tomato Soft Touch Booster Car Seat Features are included and are not limited to example of the product being ordered). 

Special Tomato Soft Touch Booster Car Seat has a contoured back that supports the natural curvature of the spine. Lateral trunk supports and head support (occipital ridge) are molded into the seat itself and help the user maintain a well aligned upright position. The contoured seat is designed to allow the ischial tuberosities (ITs) commonly called “sit bones” to comfortably sink into the seat thereby creating the stable base required for the foundation of the seated posture. The contoured seat also includes a 15 degree ramped angle with built in abductor. Both features ensure a well aligned hip position.

*Adjustable 5-Point Trunk Positioning Harness can be adjusted to fit the user as she/he grows. Shoulder straps discourage rounding of the spine by keeping shoulders back in the seat. Bottom pull straps (separate/ independent of Pelvic Positioning Harness) and center side release clasp ensure the ability of the harness to maintain an upright midline posture of the trunk.

*Adjustable 3-Point Pelvis Positioning Harness The straps across hips along with the crotch strap can be tightened to prevent sliding forward in the seat. Adjustable strapping can be loosened when less support is required.

*Please Note: Harnesses are used for positioning support only. It is the vehicles seat belt (shoulder strap and lap belt) that acts as the child’s safety restraint.

Attachment Straps (2) come standard with the Special Tomato Soft Touch Booster Car Seat. The attachment straps can be used to secure the Booster Car Seat to any stable standard chair allowing its use in many environments and eliminating the need for multiple pieces of costly equipment. The Large Booster Seat weighs only 15 lbs. compared to the typical 40-50 lbs. of a similar booster seat, making it truly portable.

*Please Note: The Special Tomato Soft Touch Booster Car Seat is compatible with the bases below for greater versatility in use.

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 and Mobile 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. The Mobile Base is the same as the Stationary Base, with the addition of wheels to allow the child to be moved room to room or to different parts of the classroom without picking up the child. The Sitter on a Stationary or Mobile Base is perfect for circle time at school, playing with friends and siblings at home or “chilling out” with the rest of the family at home.

It may also be helpful to include a picture of the Special Tomato Soft-Touch Booster Car Seat.

Thank you for taking the time to consider this request for Tariq. Please contact me if you have any questions or if you need further clarification. I can be reached at 000-000-0000.

Professional's Name (with signature above)
Professional's Title and Credentials


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.


The accuracy of the information provided was compiled & verified from the product user manual and the manufacturer’s website at the time of publication. The sample letters provided are examples based upon the intended use of the product listed and its design applications. Professional client and product evaluation is critical to the clinical advantages and appropriate application of a product for each case submitted for third party payment. There are several factors that affect the outcome of a submission and Bergeron Health Care cannot guarantee favorable outcomes in obtaining third party and insurance payments.