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: Grace is an 8 year old girl who was diagnosed with spina bifida and hydrocephalus on fetal ultrasound. Myelomeningocele was closed at birth and VP shunt was placed 1 week later. Grace has bilateral club foot deformity, trace active lower extremity movement and hip and knee flexion contractures with windswept deformity at hips.  She also has scoliosis with low tone in her trunk and neck. Grace requires moderate assistance to roll. She can ring sit with fair balance for 1-2 minutes. She exhibits significant forward trunk lean with hyperextension of her neck as she fatigues. In prone, Grace is able prop on forearms with hyperextension of her neck to hold her head up. She is able to pull herself forward in this position approximately 7’. Due to lower extremity and spinal deformities Grace is not able to stand. Grace suffered one pathological fracture of her right femur when she was 5 years old. Grace lacks sensation in her lower extremities. When Grace is given necessary postural support in sitting, she exhibits functional use of her upper extremities despite mild flexor spasticity (left greater than right) which results in a tendency to fist hands with indwelling thumb. Grace can feed herself. She enjoys coloring, peg puzzles, playing with play dough and educational computer programs that she navigates with an adapted mouse. Grace uses a power wheelchair with u-shaped joystick for independent mobility. Cognitive skills are moderately to severely impaired. Speech is generally functional but Grace expresses some frustration expressing wants and needs. Grace has bilateral AFO’s and bilateral hand orthoses. 

Example: Grace has been classified as a student with a disability. She is currently in a self-contained 12-1-1 special education classroom and receives Physical Therapy 2x30 minutes per week, Occupational Therapy 2x30 minutes per week and Speech/ Language Therapy 3x30 minutes per week per her IEP.

Current Functional Problems:

• Grace requires significant postural support in sitting to engage in functional use of her arms.
• Grace struggles to maintain her limited functional mobility skills (ring sitting when placed, pulling herself forward in prone) as she grows due to insufficient increases in muscle strength and endurance to accommodate skeletal growth. 
• Grace has begun to experience skin breakdown/ decubiti due to prolonged sitting in her power wheelchair.
• Grace can recognize letters of the alphabet and is able to trace large, dotted templates but is not yet able to form letters independently using a writing utensil.
• Grace appears frustrated at times as she struggles with self-expression due to limitations in expressive language skills.

Long Term Treatment Goals:

• Maintain integrity of skin.
• Improve functional strength and endurance.
• Grace will maintain her ability ring sit on a thickly padded activity mat with arms engaged in play.
• Grace will actively participate in a sliding board transfer from wheelchair to bed.
• Grace will maintain her ability to pull herself forward on her stomach 7’. 
• Grace will independently form 3 letters using a dry erase marker on a dry erase board.
• Grace will express 2-part complex needs without signs of frustration with 75% consistency.

Treatment Strategies:

• Maintain range of motion, improve functional strength and endurance, and manage tonal abnormalities and their limiting effects on function.
• Manage fit and wearing schedule of orthotics.
• Seat to seat transfer training with sliding board.
• Provide Grace with appropriate durable medical equipment to maximize function and promote inclusion.
• Activities/ Interventions to improve upper extremity coordination and control specifically for use of writing utensils.
• Trial with augmentative communication.

Example: As Grace’s physical therapist, I am requesting funding authorization for a Special Tomato Multi-Positioning Seat (MPS) with Hi-Low Base, Size Large Shell, MBH (Basic) Headrest, Size ML2 Back Cushion, and Size ML3 Seat Cushion. Grace requires an adaptive seating system that offers postural support to stabilize her trunk in a well aligned upright seated posture. It is only with this support that Grace can maximize functional use of her upper extremities.  It is imperative that the seating system offers tilt-in space to allow gravity to assist Grace with postural control when she is fatigued and decrease pressure on weight bearing areas in sitting. The Hi-Low Base is necessary to facilitate social emotional development through inclusion. When Grace is in her wheelchair, she interacts with her environment at one level. She currently has no opportunities to sit with the postural support she needs for longer periods of sitting close to the floor where her siblings and peers play. She also cannot be properly positioned next to the dining room table in her power wheelchair. As Grace grows, her positioning needs are changing. Skeletal growth has challenged her ability to maintain her head and trunk in alignment when ring sitting. As Grace grows her family has begun to have trouble lifting her up and down from the floor and transferring her from place to place. Grace requires a seating system that allows for supported sitting at a variety of heights for inclusion in family activities.  The Special Tomato Multi-Positioning Seat Hi-Low Seating System Size Large will accommodate over 5 years of growth. The Special Tomato MPS is an ideal seating system for Grace for the following reasons: 

Example: 3 trials, each approximately 1 hour in length, were conducted with the Special Tomato Hi-Low MPS on 5/5, 5/12 and 5/19 in Grace’s home. Grace was positioned in the Hi-Low MPS at the beginning of each session. Because the cushions are separate/ modular, they could be attached to the track system to offer optimal support. The Hip Flex Cushion was ideal to achieve optimal pelvic positioning. For the first time Grace was properly supported at floor level and enjoyed interacting with her siblings as they played on the floor. When it was time for a snack, she joined them at the table. Caregivers did not have to perform lifts down and up from the floor improving safety for Grace and her caregivers. Height changes were made using a foot pedal and the chair was wheeled from one place to another. When Grace fatigued during upright sitting, she began to lean forward into the support of her chest harness and hyperextended her neck. It was at this point that the seat was tilted back to fully support Grace’s seated posture without changing the established pelvic positioning. Grace currently has a reddened area on her right buttocks from pressure. The ability to tilt Grace back in her seat redistributes seated pressure as she is unable to perform her own weight shifting in sitting. When Grace is tilted back, she required a different seat height to be positioned to watch her favorite program on the television. None of these changes in position are possible in Grace’s power wheelchair. As Grace grows in height and weight problems such as redistribution of pressure in sitting and offering Grace support for her seated posture at levels that allow inclusion into the family’s activities becomes more and more critical.  

On 4/28 Grace trialed the Rifton Hi-Lo Activity Chair and on 5/31 she trialed the Leckey Everyday Activity Chair. The Special Tomato Hi-Low MPS was chosen over both chairs because Grace was most comfortable in it. Upper extremity function was maximized in the Hi-Low MPS as Grace was observed to stack blocks and trace letters. Grace’s family was very pleased that the seat cushions were latex free, impermeable to fluids and easy to wipe clean. Due to her spina bifida, Grace has issues of bowel and bladder incontinence. It is imperative that the seat cushion is easily cleaned when necessary to ensure skin integrity. The unique Hip Flex Technology allowed for customization of seat cushion placement in relation to the back cushion which allowed for optimal support and comfort despite Grace’s skeletal abnormalities consistent with Spina bifida. The Rifton and Leckey chairs did not offer comparable customization of cushion placement or contoured support.  As Grace grows, the Special Tomato Hi Low MPS offers the easiest means of adapting cushion placement and size to continue to optimally and comfortable support Grace. The angle of posterior tilt in space is also slightly more on the Hi Low MPS than on the other two high low seats.  

Itemization of the Special Tomato Hi-Low MPS:

Include only those product features that will be applied for.

Item

Description of Medical Necessity

Headrest Cushion

• MBH (Basic)- is designed for individuals with good head control. It offers cushioning behind the head for comfort and safety and some contouring with slightly raised edges to encourage a midline position of the head.
• MHS (Standard)- is a contoured headrest with an occipital ridge that creates a bowl shaped support for the head. Individuals who tend to hyperextend their necks due to low muscle tone and weakness or hyperextend their necks due to increased extensor hypertonicity will have the support they need to maintain their head in neutral alignment (neck elongated with a slight chin tuck).
• MBL with laterals- offers a slight occipital ridge to support head position in the sagittal plane with contoured lateral support to maintain the head in neutral rotation and discourage tilting of the head to the left or right. The lateral support provided is less than that provided by the MHL with laterals.
• MHL with laterals- offers the greatest level of head support with its bowl shaped cradling of the occiput as well as contoured lateral support. Lateral Supports are molded into the headrest at the mandibular (jaw) level NOT eye level. This ensures that the user’s visual field (peripheral vision) is NOT limited by the headrest. This headrest is designed for individuals who have difficulty maintaining neutral rotation (individuals who turn their head and have difficulty keeping eyes facing forward) or for individuals who tend to tilt their head to the right or left.

The Contoured Back Cushion supports the natural curvature of the spine. All back cushions on the MPS are secured on a hook and loop track to hold them in position. All back cushions have lateral (side) supports molded into the contour of the seat to help the user maintain a midline position. Cushions can be inverted (turned upside down) and placed back on the track to raise or lower the height of the lateral support as needed.

The Contoured Seat Cushion with Hip-Flex™ Adjustment is molded to provide medial and lateral support for the thighs to keep hips in a well aligned position. Hip-Flex™ Adjustment allows the seat cushion to be easily pivoted 30 degrees (15 degrees of hip flexion or extension from customary 90 degrees of hip flexion in sitting) to ensure proper pelvic positioning, the foundation of the seated posture, is optimal.

MPS Tray with Tray Risers- The Optional Height, Depth and Angle (60 degrees) Adjustable Special Tomato MPS Tray is required to offer a suitable surface for upper extremity weight bearing to support and assist with developing head, neck, and trunk control in sitting. The tray is also required to provide an optimally positioned work surface to maximize upper extremity function for developing fine motor skills that include activities of daily living such as self-feeding. The tray positioned at an optimal height and angle is also essential when a support surface for materials that require visual attention is needed and eye hand coordination skills are addressed.