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 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.
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