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

ICD 10 Code: Code for Diagnosis Example G12.1 Spinal Muscular Atrophy (SMA) type 2

Height: _ inches

Weight: _ pounds

Address: Patient’s Address

Parent/ Guardian’s Name:

Parent/ Guardian’s Phone Number:

Example: Tyshawn is a 10-month-old boy born at 37 weeks gestation. Ultrasound results prior to his birth were remarkable for mildly reduced fetal movement. He was diagnosed with spinal muscular atrophy (SMA) type 2 shortly after birth through blood testing. Treatment has included the medication Nusinersen and Early Intervention Services. Tyshawn currently presents with mildly decreased tone and weakness in both core and extremity muscles. He became consistent in his ability to roll from stomach to back at 6 months old and from back to stomach at 8 months old. Head and trunk control are slowly improving. Tyshawn is able to ring sit on the floor with minimal to moderate assistance at mid-trunk. He participates in moving into and out of the sitting position but requires moderate assistance to complete this transition. Righting and protective reactions in sitting are delayed/weak. Tyshawn requires moderate to maximal assistance to transition into and hold the hands and knees position. He is not yet attempting to rock or move forward in quadruped. When held in the standing position, Tyshawn briefly/inconsistently bears weight through his legs.

Tyshawn lives with his mother and grandmother and two older siblings who also have special needs.   

Tyshawn does not own any durable medical equipment at this time.       

Example: Tyshawn receives Early Intervention Services. He receives Physical Therapy 1x30 minutes per week, Occupational Therapy 1x30 minutes per week and Speech/ Language Therapy 1x30 minutes per week to address communication and feeding.

Current Functional Problems:

• Tyshawn requires moderate assistance to ring sit
• Tyshawn requires moderate assistance to push up into sitting
• Tyshawn can roll independently but has no other form of independent mobility
• Tyshawn requires moderate to maximal assistance to maintain the quadruped position
• Tyshawn is not consistent in his ability to accept weight through his legs in standing

Long Term Treatment Goals:

• Tyshawn will ring sit when placed on the floor for 3 minutes with close supervision.
• Tyshawn will push up to sitting through side sitting with supervision
• In a supported sitting position, Tyshawn will bring a sippy cup to his mouth independently using both hands together
• Tyshawn will move from ring sitting to quadruped with minimal assistance
• Tyshawn will creep forward 3’ on hands and knees
• Tyshawn will pull to stand with support of furniture
• Tyshawn will stand with support of furniture for 2 minutes and close supervision

Treatment Strategies:

• PT and OT to address progressive strengthening/ endurance program to improve core stability for greater independence in upright postures.
• Activities/Interventions to improve extremity coordination and control specifically during transitional movement patterns such as pushing to sit and pulling to stand.
• Introduction of strategies to increase independence in self-feeding.
• Speech/ Language Therapy to address strength/endurance of facial musculature and improve sound production.  

Example: As Tyshawn’s physical therapist, I am requesting funding authorization for a Special Tomato EIO Push Chair/Jogger (use only the model that you have chosen to purchase) with Special Tomato Soft Touch Liners. Tyshawn is currently using a commercially available umbrella stroller when he leaves his home with his caregivers for medical appointments and community activities. The umbrella stroller does not offer the support Tyshawn requires for a well aligned upright seated posture. The umbrella stroller exacerbates the rounded spine and forward head posture which is common in children with low muscle tone and weakness. Concerns have also been raised about Tyshawn’s lung capacity and his ability to maintain a fully open airway in this forward leaning “collapsed” posture. 

SMA type 2 is a hereditary genetic disorder that causes progressive muscle weakness in children. Symptoms most often start between the ages of 6 and 18 months. Each child’s course is unique but generally children with this type of SMA eventually sit without support but often do not walk on their own. Children with SMA type 2 often develop a scoliosis which can eventually impact their lung capacity. Offering necessary support for proper alignment during sitting is essential to work towards improved head and trunk control in sitting, slow the progression towards/prevent  boney deformities such as scoliosis and maintain a posture that optimizes respiration.  

The Special Tomato EIO Push Chair/Jogger (use only the model that you have chosen to purchase) can also be fit with either Special Tomato Soft Touch Liners or a Soft Touch Sitter for greater postural support as needed. 

Itemized Description of Medical Necessity for Special Tomato EIO Push Chair standard features. 

• Padded Hip and Trunk Lateral (side) Supports help the user maintain a well-aligned upright position. They are removable and can be used in a variety of configurations as the support needs of the user changes. Learn more about the Lateral Supports https://www.adaptivemall.com/eio-push-chair-lateral-pads-uses  here if further specific information for medical justification is required.
• Height Adjustable Head Pad provides support and comfort. The headrest is especially useful when the back of the pushchair is reclined for rest or caregiving.
• Adjustable 5-Point Padded Chest Harness with Shoulder Pads ensures that once the user’s well-aligned position is achieved it can be comfortably secured. Trunk is held in midline with shoulders back.
• Padded 3-Point Locking Pelvic Belt ensures that once an optimal position of the pelvis is achieved it can be secured. Proper, stable positioning of the pelvis is the foundation of the seated posture. It is critical for users who have limited core strength or abnormalities in muscle tone.
• Angle Adjustable Foot Well with a 2-Position Foot-Block provides supportive lower extremity positioning. Leg rest angle adjustment moves from +15 degrees to -55 degrees. The fact that the leg rest can be fully extended is especially important when the recline function of the back is being used. The Foot-Block offers a surface area to rest the feet for younger, smaller children whose feet do not reach the base of the foot well. Lower extremity weight bearing through a foot flat resting position on a supportive surface helps to stabilize the seated posture.
• Back Rest Angle Adjusts from 25 Degrees to 75 Degrees of Recline. Adjusting the push chair’s seat back into a greater angle of recline offers the user greater support and reduces their energy expenditure in sitting. This is especially important for children with decreased strength and endurance of postural muscles who can fatigue quickly. The reclining back in combination with the elevating leg rests also provides full support for the user when napping or when diaper changes or other medical care is required.
• Sun Canopy provides protection from UV rays especially important for users who are on medications that may cause photosensitivity. 

Itemized Description of Medical Necessity for Special Tomato Jogger standard features. 

Description of Medical Necessity for OPTIONAL Soft Touch Seat and Back Liners 

Description of Medical Necessity for OPTIONAL Soft Touch Sitter

The Special Tomato Soft Touch Sitter provides 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. 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 (pommel that separates legs). Both features ensure a well aligned hip position that discourages extensor thrusting. The Soft Touch Sitter can be attached to the EIO Push Chair, the Jogger or any stable standard chair using attachment straps. It is also a portable postural support seating system that can be easily carried to anyplace you might need it.

Please Note: Special Tomato Soft Touch Sitters can also be attached to dining room chairs, restaurant chairs, classroom chairs and office chairs. Dedicated indoor bases are also available. Versatility in use of the equipment you are requesting can and should be mentioned in a Letter of Medical Necessity. It can also be mentioned that there are 2 sizes of sitters that fit the EIO and Jogger allowing for customization of support and accommodating growth at a low cost. 

A full Letter of Medical Necessity for the Special Tomato Soft Touch Sitter can also be found here. 

Example: During a trial on 9/6 Tyshawn was given additional support using blanket rolls and polyethylene pool noodles to help align his posture in his own umbrella stroller. These supports did not stay in place because the umbrella stroller lacked a side support frame to buttress the additional support.  On 9/9 a Convaid Coaster was trialed and it worked well to support Tyshawn but cost was $1,769 compared to the Special Tomato EIO at $699.95/ Special Tomato Jogger at $799.95. The Special Tomato EIO Push Chair was trialed on 9/12. Tyshawn required more postural support than the EIO provided alone so both the Soft Touch Liners and Sitter were trialed. The Sitter offered more support than Tyshawn needed causing him to be fully dependent on the supporting surface which would ultimately not serve developing core strength. The contoured Liners however offered the support that Tyshawn requires for a well aligned posture without discouraging the use of his own postural muscles as he sits. The fact that the EIO reclines while the Convaid Coaster has an adjustable fixed tilt and recline also served Tyshawn’s needs more completely. If his postural control improves the Liners can be removed. If Tyshawn’s weakness becomes more significant, a sitter can be purchased at a reasonable price without purchasing a whole new stroller. Tyshawn’s family was also pleased with the idea that the liners are versatile and can be used to support him when sitting in other pieces of furniture at home and in the community.