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Sample Letter of Medical Necessity for Special Tomato® Multi-Positioning Seat (MPS)

The Sample Letter of Necessity below includes guidance as well as examples you can tailor to your own needs. 

Tip: Contact the beneficiary's insurance company and ask them to provide you with their definitions of medical necessity. Be sure to include all components in your letter while using the samples below as a general guideline.

Download PDF of this letter


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:

 

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.  

 

Example: John is 4 year old boy who was diagnosed with spastic quadriplegia at 15 months old. He has mild to moderate extensor spasticity of his trunk and lower extremities and mild to moderate flexor spasticity of upper extremities. Range of motion is currently within normal limits throughout trunk and extremities. John has fair to good head control in supported sitting. John can roll to the right and left independently with increased time and effort and decreased fluidity of motion. He can ring sit propped on extended arms for approximately 2 minutes when placed. He requires close supervision when sitting due to an exaggerated startle response that can cause him to lose his balance. Balance, righting/ equilibrium reactions, as well as protective extension are not yet functional in sitting. He requires moderate to maximal assistance to recover from loss of balance when sitting.  John requires minimal assistance to push up into the side sitting position from side lying. He requires moderate assistance to then transition to ring sitting or long sitting. John requires moderate to maximal assistance to transition from ring sitting to quadruped. He can hold the quadruped position for approximately 1 minute with close supervision to minimal assistance but is not yet able to move forward in this position. He can pull himself forward on his stomach approximately 3 feet when motivated and is able to prop on forearms in prone with head held steady in a face vertical position for approximately 2 minutes.  John can bench sit with minimal assistance to close supervision for approximately 3 minutes. He can transition from bench sitting to standing using a R.E.A.L. Design Rise and Shine Ladder at his preschool and can remain in standing bearing weight through both legs for 1-2 minutes while grasping the ladder rungs for support. John is beginning to take steps using a loaned Rifton Dynamic Gait Trainer with many accessories to support his posture. He participates in a daily standing program using his preschool’s supine stander and can tolerate a fully upright position for 25 minutes with tray in place for upper extremity weight bearing to assist with stability as he develops postural control.

 

Current Program of Intervention: List specific functional problems. List long term treatment goals. Describe what is being done to help the child achieve these goals. 

 

Example: John has been classified as a preschooler with a disability and receives related services through his school district per his IEP. He receives Physical Therapy 2x45 minutes per week, Occupational Therapy 2x30 minutes per week and Speech/ Language Therapy 3x30 minutes per week to address communication and feeding.

Current Functional Problems:

  • John’s requires close supervision to balance in sitting. He requires moderate to maximal assistance to recover from loss of balance in sitting.
  • John requires physical and/ or structural assistance for all transitional movement patterns.
  • John’s ability to maintain weight bearing through his legs is limited to 1-2 minutes when not in a fully supportive stander. He requires structural support (grasping sit to stand ladder) to maintain standing.
  • John requires intermittent physical assistance during self-feeding with a spoon.
  • John requires supportive therapeutic positioning for safe chewing and swallowing.
  • John’s expressive functional vocabulary is limited to 20 words.

Long Term Treatment Goals:

  • John will push to sitting through side sitting with supervision only.
  • John will ring sit for 5 minutes while hands are engaged in play and he will recover sitting balance independently after startling.
  • John will move from ring sitting to quadruped with minimal assistance.
  • John will push to stand moving from bench sitting to standing with support of an appropriate walker.
  • John will take steps using appropriate walker for support.
  • John will feed himself with a spoon independently.
  • John’s expressive functional vocabulary will increase to 50 words to allow him to express his wants and needs.

Treatment Strategies:

  • Maintain range of motion, improve functional strength and endurance, and manage tonal abnormalities and their limiting effects on postural control and functional mobility.
  • Improve postural control in all developmental positions.
  • Functional Mobility Training focusing on transitional patterns of movement.
  • Daily Stander Program
  • Provide John with appropriate durable medical equipment to maximize function and support progression of function.
  • Activities/ Interventions to improve upper extremity coordination and control specifically hand to mouth behaviors, bilateral hand use for manipulation of objects during exploration and play, and ability to cross midline.

 

Rationale for Treatment with Therapeutic Equipment: Describe how the piece of equipment will medically benefit the child. How will the equipment reduce the need for other services? What might be the medical impact if this piece of equipment is denied? Identify the aspects of the child’s life that the equipment will be of assistance and how will it improve the child’s level of function in the home. Identify how the equipment will enable treatment goals to be met. Be specific. 

 

Example: As John’s physical therapist, I am requesting funding authorization for a Special Tomato Multi-Positioning Seat with Mobile Base, Size Small Shell, MHS (Standard) Headrest, Size MS4 Back Cushion, Size MS3 Seat Cushion and Tray Size Small. John requires an adaptive seating system that offers postural support to stabilize his head and trunk in a well aligned upright seated posture. It is only with this support that John can begin to maximize functional use of his upper extremities and be able to maintain a stable visual field for learning. It is also imperative that the seating system does not over support John but allows opportunities for freedom of movement and the ability to move from active postural control to full support as needed in the process of developing core strength, balance reactions, and righting/ equilibrium reactions.  Adequate postural support is also imperative during feeding as coordination of chewing and swallowing is comprised by instability of head and neck postures and places John at risk for aspiration. As John grows, his positioning needs will change. The Special Tomato Multi-Positioning Seat (MPS) Size Small with Mobile Base provides up to six years of growth along with the capability to adjust and accommodate John's changing positioning needs. The Special Tomato MPS is an ideal seating system for John for the following reasons: 

 

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.

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 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. 

 

Example: Trials were conducted on 11/5, 11/6 and 11/7 with Special Tomato MPS with Mobile Base. The MPS was trialed with shell in 10 degrees of tilt and seat cushion pivoted 15 degrees forward. This encouraged John to sit upright slightly away from the back cushion as he engaged in use of both hands with objects on his tray. When he fatigued, he was able to lean back into the back cushion and headrest for support. With encouragement, he resumed activation of his core muscles again moving away from the back cushion and engaging in slight forward lean to interact with objects on his tray. It is through independent management of these movements and weight shifts in all planes that John will gradually and safely build the strength and endurance of core muscles needed to gain greater independence in postures that require stability when upright against gravity such as sitting, quadruped and standing. The fact that the MPS Seat is highly versatile and can be used with or without the mobile base means that John and his family will use this piece of equipment consistently in many environments offering John the high frequency of opportunities that are required to build strength and endurance of core muscles. The MPS will be used during therapy and what John begins to accomplish in therapy will naturally be carried over outside of therapy. Adjustment of hip flex cushion angle ensures that we will be able to offer John postural challenges to build strength and endurance of core muscles that can only be offered through independent dynamic control of the tilt of the pelvis. The fact that the MPS allows for customized lower extremity positioning with a height, depth and angle adjustable footplate and stabilizing foot straps was also observed during trials to make a significant difference for John in his seated stability by allowing optimal weight bearing through legs to support his seated posture.  

Other trials included working on developing core strength in sitting using the Rifton Activity Chair. This trial was also successful but the Rifton activity chair does not have the same versatility in use as the Special Tomato MPS Seat. The MPS Seat can be easily detached from its base and can be securely attached to most stable, standard straight back chairs. The fact that the MPS is also a car seat and can be used for air travel is important to John’s family as they travel often using both forms of transportation. To have one piece of equipment that meets so many needs, has over 5 years of growth potential with the ability to replace cushions to meet changes in positioning needs that naturally occur due to growth and/ or changes in neuromuscular status is valued by this family who live in a small home and have legitimate concerns regarding accumulation of positioning equipment. The Special Tomato Soft Touch Sitter was also trialed but was not as effective in stabilizing Johns seated posture due to the absence of customizable lower extremity positioning with the adjustable footrest and foot straps. Because the MPS allows John’s care givers to customize the size of back and seat cushions and the type of head support he will receive through his headrest, the MPS is thought to better meet John’s needs today and as he gains greater independence in seated postural control in the future.   

 

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.


Professional's Name (with signature above)
Professional's Title and Credentials


Itemization of the Special Tomato Multi-Positioning 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.


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.


The accuracy of the information provided was compiled & verified from the product user manual and the manufacturer’s website at the time of publication. The sample letters provided are examples based upon the intended use of the product listed and its design applications. Professional client and product evaluation is critical to the clinical advantages and appropriate application of a product for each case submitted for third party payment. There are several factors that affect the outcome of a submission and Bergeron Health Care cannot guarantee favorable outcomes in obtaining third party and insurance payments.