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: 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.

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.

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.

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.

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.