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 Multi-Positioning Seat (ALL Special Tomato Multi-Positioning Seat Features are included and are not limited to example of the product being ordered).
The Special Tomato Multi-Positioning Seat (MPS) Shell 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. Built-in Attachment Straps allow the MPS Seat to be safely and securely attached to most stable, standard, straight back chairs found in the home, community, and school. This versatility facilitates the inclusion that is essential to the wellbeing of people with special needs during learning, play, socializing, and relaxation. Versatility of this single piece of equipment extends further when it is properly installed in a car. The MPS conforms to all required Federal Motor Vehicle Safety Standards (FMVSS213 compliant) allowing it to be used as a Car Seat. The MPS has also been successfully tested and approved for Aircraft Travel (FAA approved). Please Note: The footrest must be removed when the MPS seat is used as a car seat or when used for aircraft travel. This is a simple tool free process. The Footrest has not been crash tested in a vehicle.
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. 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 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.
Mobile Floor Base- allows for 10 - 25 degrees of Tilt-In-Space to accommodate a range of positioning needs. At 25 degrees posterior tilt the MPS can offer full gravity assisted support to the seated posture. By bringing the seat to a nearly upright position and using the Hip-Flex Adjustment of the Seat Cushion the user can work on independent control of the head, neck, trunk, and pelvis in a safe environment. The Mobile Base is equipped with 4 swivel locking casters for easy maneuvering at home or around the classroom. Because the seat can be moved with the user in place, it decreases the frequency of lifting and transfers required throughout the day which improves safety and decreases energy expenditure for both the user and caregivers.
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 Special Tomato MPS Seat with Mobile Base.
Thank you for taking the time to consider this equipment for John. The Special Tomato Multi-Positioning Seat with Mobile Floor Base and Optional Tray will provide proper positioning for John to continue to learn and develop to his fullest potential.
If you have any questions regarding this matter, I can be reached at 1-333-555-4444.
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