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 MPS Car Seat
The Special Tomato MPS Shell offers a firm and stable frame for the 3 contoured cushions that come standard with the MPS Car Seat (Headrest, Back and Seat). The MPS conforms to all required Federal Motor Vehicle Safety Standards (FMVSS213 compliant). The MPS has also been successfully tested and approved for Aircraft Travel (FAA approved). The MPS Car Seat comes standard with Built-in Attachment Straps allowing the seat to be safely and securely attached to most stable, standard, straight back chairs found in the home, community, and school. This versatility in use is not found in other car seats that are designed for children this age. It is unique to this brand of car seat.
Please Note: The SMALL Special Tomato™ Multi-Positioning Seat is designed for use only by children who weigh between 20 and 80 pounds (9 and 36 kilograms) and whose height is between 32.5 and 50 inches (82.5 and 127 centimeters) for Type I & Type II belts. The LATCH Belt is designed for children who weigh between 20 and 40 pounds (9 and 18 kilograms).
The LARGE Special Tomato™ Multi-Positioning Seat is designed for use only by children with a max weight of 130 lbs (59 kilograms) and whose height is between 50 and 63 inches (127 and 160 centimeters).
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 and depth. 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 Harness (Car Seat Grade) can be adjusted for optimal postural support and or growth. Shoulder Straps discourage rounding of the spine with forward head and shoulders and anterior trunk lean by keeping shoulders back. Lap Belt with Crotch Strap maintains proper pelvic position. The harness is also a safety measure when the MPS is used as a seat and an approved restraint when the MPS is used as a car seat.
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 Special Tomato MPS Car Seat.
Thank you for taking the time to consider this car seat for Neveah. The Special Tomato MPS Car Seat will meet many of Nevaeh’s current needs with one cost effective piece of equipment.
If you have any questions regarding this matter, I can be reached at 1-333-555-4444.
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