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.
Itemized Description of Medical Necessity for Special Tomato Hi-Low MPS
(ALL Special Tomato Hi-Low MPS Features and ALL Accessories are included and are not limited to example of product being ordered).
The Special Tomato Multi-Positioning Seat (MPS) Shell with Hi-Low Base offers a firm and stable frame for the 3 contoured cushions that come standard with the seat (Headrest, Back and Seat). It also comes standard with an easily removable angle, depth, and height adjustable Footrest with Foot Straps (Hook and Loop Closure). Stabilization of a well aligned seated posture includes stabilization of lower extremity position with feet resting comfortably on a supportive surface. The adjustable Footrest ensures proper positioning of the legs. The base offers pedal activated adjustment for the Hi-Low function. Tilt-in-Space Lever is located under the seat back and can be operated with the child in the seat. The lever moves the seat from 30 degrees posterior tilt to 5 degrees anterior tilt. With posterior tilt, gravity will encourage the child to lie back into the support of the seat and back but will not alter the optimal hip angle that can be established using the Hip-Flex Seat Cushion. When child is sitting upright to engage in tabletop activities the seat can be tilted forward to encourage activation of core muscles for independent management of head and trunk control while engaging arms in play, turning pages of a book, coloring and writing. The Hi-Low feature allows the child to have the postural support that is needed in sitting from floor to table heights and anywhere in between placing him/her at optimal level for upper extremity function in relation to work surface and optimal level to maintain visual attention and attention to task.
MPS Cushions provide comfortable contoured postural support to ensure a well-aligned midline position. The ability to choose the style of the headrest and the size of the seat and back cushions ensure the fit is as snug or loose as is therapeutically appropriate. Individuals with poor postural control that rely heavily on postural supports to maintain alignment will benefit from cushions that fit snuggly. Individuals who have or are progressively gaining independent postural control will benefit from more loosely fitting support, so they are given the opportunity to activate their core muscles to maintain postural alignment and shift their weight. The MPS offers easy adjustment for placement of the cushions using hook and loop attachment on the shell’s track system. The Headrest Cushion and Back Cushion are simply moved up to accommodate growth in height. Cost effective cushion replacements allow for accommodation of increases in width. Multiple cushion sizes are also ideal for individuals who are not typically proportioned. Cushion changes needed to accommodate other physical and functional changes for example improved head control are also simple and cost effective. Replace one cushion or replace them all, whatever is needed.
- 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. Lateral trunk supports are molded into the cushion and help the user to maintain a well aligned midline upright position.
The Contoured Seat Cushion with Hip-Flex™ Adjustment 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 seat cushion is also contoured 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 pelvic positioning, the foundation of the seated posture is optimal.
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. All straps are wide and padded for pressure distribution and comfort.
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, and the user is able assume more sustained control over postural muscles. All straps are wide and padded for pressure distribution and comfort.
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.
Equipment Trials: What technology has been tried and what were the results. Use objective data and results.
It may also be helpful to include a picture of the equipment being requested.
Thank you for taking the time to consider this equipment for Grace. The Special Tomato Hi-Low MPS will provide proper positioning for Grace to continue to learn and develop to her fullest potential.
If you have any questions regarding this matter, I can be reached at 1-333-555-4444.
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