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: Nevaeh is 5 year old girl who was diagnosed with Down syndrome during prenatal testing. She was born at 35 weeks gestation and went home after 3 weeks in the NICU. Nevaeh had an atrioventricular septal defect (AVSD) which was repaired at 4 months of age. She has low muscle tone throughout her trunk and extremities and joints are hypermobile due to ligamentous laxity. Strength is decreased when compared to typically developing peers. Nevaeh can sit upright with good head and trunk control in both ring sitting and bench sitting but tends to fatigue rapidly. This results in a posterior pelvic tilt, rounding of the spine and forward head. Nevaeh lacks good mid-range control of her knees and often hyper extends her knees when standing. Gait is significant for a wide base of support with external rotation of hips and toeing out and increased lateral displacement. She is not yet demonstrating a true running pattern.  Nevaeh can transition through all developmental positions independently however she does not yet transition from the floor to standing through half kneeling but pushes up through plantigrade. Nevaeh can unweight one foot briefly when asked to balance on one foot but does not achieve static single limb stance. She requires one hand held to walk heel to toe on a wide balance beam. Nevaeh has just begun to jump clearing both feet from the floor and is not yet consistent in this skill. She can walk up and down stairs with one hand on the rail placing both feet on each step with close supervision. Nevaeh is able negotiate steps reciprocally with one hand held in addition to one hand on the rail for support. Nevaeh is able to pedal and steer a lightweight tricycle approximately 10’. She can catch a playground ball trapping the ball to her chest with arms. She is not yet performing a hands only catch. Nevaeh throws underhand and overhand without trunk rotation or a step towards the target.

Example: Nevaeh has been classified as a student with a disability. She is in a general education kindergarten classroom with a full time aide. She receives Physical Therapy services 1 x 45 minutes per week in a group. She also participates in Adapted Physical Education class.  Nevaeh receives Occupational Therapy 1x30 minutes per week individually and 1x30 minutes per week in a group. She receives individual speech therapy 2x30 minutes per week. All services are provided per IEP.  

Current Functional Problems:

• Nevaeh does not yet have sufficient strength, endurance, balance, and coordination to achieve age appropriate gross motor milestones.
• Nevaeh is not yet able to balance on one foot.
• Nevaeh is not yet able to negotiate stairs foot over foot independently.
• Nevaeh is not yet jumping consistently.
• Nevaeh is not yet able to cut along a straight line with scissors.
• Nevaeh is not yet able to copy a circle.
• Expressive and receptive language skills are moderately delayed.

Long Term Treatment Goals:

• Nevaeh will transition independently from floor sitting to standing through half kneeling.
• Nevaeh will jump forward 8” engaging in a 2-footed take-off and landing with 80% consistency.
• Nevaeh will walk up and down a flight of stairs with one hand on the rail for support placing one foot on each step with close supervision.
• Nevaeh will cut along a straight line with scissors with 75% consistency.
• Nevaeh will copy and circle, triangle, and square with 75% consistency while holding the writing utensil in a mature grasp.
• Nevaeh will independently initiate verbal participation in circle time at least 2x per week.

Treatment Strategies:

• Improve functional strength, endurance, balance, and coordination to support progression of gross and fine motor development.
• Functional Mobility Training to facilitate maturation of existing skills (i.e. moving from floor sitting to standing through half kneeling without hand support, running, jumping, stair negotiation).
• Provide Nevaeh with appropriate durable medical equipment to ensure safety and maximize function.
• Facilitate maturation of fine motor skills with emphasis on those skills required for greater independence in ADL’s and schoolwork.
• Improve speech and language skills to promote inclusion with peers.

Example: As Nevaeh’s physical therapist, I am requesting funding authorization for a Special Tomato MPS Car Seat, Size Large Shell, MBH (Basic) Headrest, Size ML2 Back Cushion, Size MLS Seat Cushion. Nevaeh has outgrown commercially available car seats but continues to require postural support  and will for many years to come when traveling in a car due to low muscle and decreased strength/ endurance of postural muscles. Nevaeh fatigues rapidly when sitting and this is especially true in the car. Nevaeh requires lateral support to keep her in a well aligned upright position. When she is properly supported her tolerance for car rides improves and safety restraints remain properly positioned at all times.

The Special Tomato MPS Car Seat is ideal for Nevaeh for the following reasons: 

For Example: The MPS Car Seat was trialed on 12/2. Nevaeh was observed to be comfortable in the seat and per mother was tolerating car ride “very well”. This provider and family were pleased with the idea that cushions can be easily adjusted and/or replaced to accommodate growth. Versatility in use of the MPS as a supportive seat in the community when the seat is strapped to a standard, stable straight back chair especially when the family has driven to a destination for an activity that will include prolonged sitting was very important to this family. It was also very important that the MPS Car Seat can be used in an airplane. The family travels frequently to Europe to visit with extended family. The R82 Wallaroo Car Seat, Columbia Medical Spirit APS Car Seat and the Columbia Medical IPS Car Seat were all trialed. None of these car seats offered the modular, adjustable cushions to optimize the configuration of postural support for Nevaeh today AND can continue to provide this optimal support as Nevaeh grows and postural support needs change. None of the other car seats offered the versatility in use of the Special Tomato MPS Car Seat as a supportive seat approved for air travel and as a supportive seat that can be used in the community. The Special Tomato MPS Car Seat meets many of Nevaeh’s current needs with one cost effective piece of equipment.

Itemization of the Special Tomato MPS Car Seat:

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.