FREE SHIPPING* on all orders | See Details

Sample Letter of Medical Necessity for Special Tomato® Soft-Touch® Sitter

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: Samantha is a medically fragile 2 year old girl with moderate hypotonia diagnosed at 5 months of age. She has also been diagnosed with global developmental delay. Samantha intermittently requires supplemental oxygen and receives all nutrition through a feeding tube. When in an upright seated position, Samantha's head and trunk control is just beginning to emerge. She can hold her head steady in a well aligned upright position for approximately 45 seconds when she is given full support at her hips and moderate to maximum trunk support under axilla. Her righting and protective reactions in sitting are delayed or absent. Samantha can roll independently and actively participates in pushing up to sitting through side sitting when given moderate assistance.
Samantha owns a pediatric wheelchair that she uses for transport to and from her daycare for medically fragile infants and children. Samantha also owns a 3-in-1 stander that she uses for her daily standing program.

 

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: Samantha receives Early Intervention Services. She receives Physical Therapy 2x30 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:

  • Samantha requires moderate to maximal assistance when upright against gravity in the sitting position.
  • Samantha engages in extensor thrusting patterns when agitated.
  • Samantha requires maximal assistance to stand.
  • Samantha can roll independently but has no other form of independent mobility.

Long Term Treatment Goals:

  • Samantha will ring sit when placed on the floor for 3 minutes with close supervision.
  • Samantha will push to sitting through side sitting with minimal assistance.
  • In a supported sitting position, Samantha will bring a sippy cup to her mouth independently using both hands together.
  • 25% of Samantha’s daily nutritional intake will be by mouth.

Treatment Strategies:

  • PT and OT to address progressive strengthening/ endurance program to improve core stability for greater independence in upright postures.
  • Daily Stander Program
  • Activities/ Interventions to improve extremity coordination and control specifically hand to mouth and stepping behaviors.
  • Feeding Therapy currently focusing on intake of thickened liquids and issues of oral hypersensitivity.
  • Speech/ Language Therapy addresses meaningful vocalization and communication through gestures.

 

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 Samantha’s physical therapist, I am requesting funding authorization for a Special Tomato Soft Touch Sitter with Wedge Floor Sitter Base. Samantha’s current pediatric wheelchair offers maximum postural support required when she is being transported or is sitting for long periods of time, but the wheelchair is restrictive and limiting to the development of her own postural control in sitting. A Special Tomato Soft Touch Sitter will facilitate the sitting opportunities required to work towards independent sitting in a cost effective manner. The Soft Touch Sitter can be adjusted from fully upright to 25 degrees of posterior (backwards) tilt. This allows Samantha to work on her ability to sit fully upright managing her own postural control to her tolerance. As the strength and endurance of her postural muscles improve, Samantha will be able to sit fully upright for longer and longer periods of time. When Samantha is fatigued, the sitter can be tilted back to allow gravity to assist her in maintaining a well aligned midline position of her head and trunk. The ability to offer Samantha a variable 0 to 25 degrees of tilt is also imperative for safe positioning during feeding by mouth. Because the sitter is light weight and can also be strapped to a standard chair, it will be used frequently by Samantha’s family in home, school and community environments to offer Samantha the support she needs to sit upright today and as she becomes more independent in her sitting skills.

 

Itemized Description of Medical Necessity for Special Tomato Soft Touch Sitter
(ALL Special Tomato Sitter Features and ALL Special Tomato Sitter accessories are included and are not limited to example of product being ordered).

The Special Tomato Soft Touch Sitter has a contoured back that supports the natural curvature of the spine. Lateral trunk supports and head support (occipital ridge) are molded into the seat itself and will help the user maintain a well aligned upright position. They provide support as needed for safe sitting but do not over support the user when they are able to activate their own core muscles to manage an upright well aligned posture. The contoured seat 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 contoured seat also includes a 15 degree ramped angle with built in abductor. Both features ensure a well aligned hip position that discourages extensor thrusting in the seat. Because the Special Tomato Sitter does not over support the user, the user has the freedom to begin to develop their own independent weight shifting abilities often not possible in restrictive pediatric wheelchairs. The soft to the touch surface of the Sitter is textured to discourage sliding forward. It is also impermeable to fluids, easily wiped clean, has antimicrobial properties, is latex-free, and peel- and tear-resistant.

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.

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.

Attachment Straps (2) are used to secure the Sitter to the Base. The attachment straps can also be used to secure the Sitter to a stable standard chair, classroom chair or stroller in the community, home, or school. The straps allow the lightweight portable Sitter to be utilized in many environments, thus eliminating the need for multiple pieces of costly equipment.

Floor Sitter Base- Tilt-in-space positioning allows for fully upright sitting or sitting tilted back as far as 25 degrees and anywhere in between. This allows the user to engage postural muscles to varying degrees as tolerated and as activity dictates. With the Floor Sitter Wedge Base, the user can be positioned sitting on the floor where peers and siblings typically play. Imitation of peers is a profound motivator for independent function. Without the support of the Sitter in the Floor Wedge Base a child who is not sitting independently may need to lie on the floor which is not an inclusive position beyond the age of approximately 6 months.

Stationary Base and Mobile Base- The Stationary Base allows children to be close to the floor without caregivers having to transfer them all the way down to the floor. The Stationary Base is equipped with furniture glides to protect floors. The Mobile Base is the same as the Stationary Base, with the addition of 3 in. locking urethane casters to allow the child to be moved room to room or to different parts of the classroom without picking up the child. The Sitter on a Stationary or Mobile Base is perfect for circle time at school, playing with friends and siblings at home or “chilling out” with the rest of the family at home.

Headrest- offers additional head support to users who have difficulty holding their head upright and forward facing. The lateral or side support of the headrest prevents excessive rotation or listing of the head to the right or left.

Equipment Trials: What technology has been tried and what were the results. Use objective data and results.

Example: During trials on 9/6, 9/7 and 9/9 with Special Tomato Sitter in a fully upright position Samantha was able to move first her head and then her back away from the back of the Sitter for 3-5 seconds at a time with positioning harnesses in place and hands resting on lateral thigh supports. The effort required to engage in this activity did not allow Samantha to engage in functional arm use. The Special Tomato Sitter was then tilted back 25 degrees. With gravity assisting the midline position of her head and trunk Samantha was able to bring a rattle placed in her hand to her mouth for approximately 1 minute.

Other trials included working on developing core strength in sitting using supportive Boppi pillows. Pillows were not able to offer enough support and did not remain stationary when Samantha leaned into them during floor sitting. Trial with a Tumble Forms Universal Corner Floor Sitter was successful, but it does not offer the tilt positioning that is how progressive postural control will be achieved. Opportunities for use of the corner floor sitter are much more limited and the surface of Tumble Forms products is slippery which resulted in Samantha frequently sliding forward in the seat.

It may also be helpful to include a picture of the Special Tomato Soft-Touch Sitter.

Thank you for taking the time to consider this request for Samantha. Please contact me if you have any questions or if you need further clarification. I can be reached at 000-000-0000.

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


Itemization of the Special Tomato® Soft-Touch Sitter:

Include only those product features that will be applied for.


Item


Description of Medical Necessity


Floor Sitter Base -Tilt-in-space positioning allows for fully upright sitting or sitting tilted back as far as 25 degrees and anywhere in between. This allows the user to engage postural muscles to varying degrees as tolerated and as activity dictates. With the Floor Sitter Wedge Base, the user can be positioned sitting on the floor where peers and siblings typically play.


Stationary Base - The Stationary Base allows children to be close to the floor without caregivers having to transfer them all the way down to the floor. The Stationary Base is equipped with furniture glides to protect floors.

 

 


Mobile Base - The Mobile Base is the same as the Stationary Base, with the addition of 3 in. locking urethane casters to allow the child to be moved room to room or to different parts of the classroom without picking up the child.

 


Headrest- offers additional head support to users who have difficulty holding their head upright and forward facing. The lateral or side support of the headrest prevents excessive rotation or listing of the head to the right or left.


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.