Sample Letter of Medical Necessity for Special Tomato® Soft-Touch Sitter
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 sample below as a general guideline.
December 17, 2009
Any Insurance Company
123 Any Street
Any City, Any State 12345
Re: Patient's Name
DOB: Patient's DOB
ID #: Insurance ID #
Explain the beneficiary's condition, including the diagnosis and impairments. Also include any other equipment that may be pertinent.
Samantha is a 3 year old girl with global developmental delay. When in an upright seated position, Samantha's head and trunk fall forward or to the side. Her righting and protective reactions are delayed or absent, which makes sitting on a surface without support unsafe. If she falls, she cannot put her arms out to catch and protect herself. Samantha requires total support at her hips, trunk, and head to sit upright for greater than a few seconds. Samantha has a tilt in space wheelchair which is her primary means of mobility.
Explain what equipment you are requesting and how it will improve the beneficiary's function. Include all components that are pertinent.
Samantha has a wheelchair which is her primary means of mobility. She does not have a seating system for feeding, therapies, or general positioning at home, school, or in the community. I am requesting funding authorization for the Special Tomato Soft-Touch Sitter with the Mobile Tilt Wedge Base. The Soft-Touch Sitter with the Mobile Tilt Wedge Base has the following components which will benefit Samantha:
-Abductor- This provides leg separation and keeps Samantha's hips aligned which is essential for the integrity of her hip joints.
-Adjustable 5 point harness- This includes shoulder straps, a hip belt, and a crotch strap. This harness can be adjusted to fit Samantha as she grows. The straps across her hips can be tightened to prevent her from sliding forward in the seat. The crotch strap is beneficial to position her hips and prevent forward displacement of her pelvis.
-Contoured seat and back with head and lateral trunk supports- The contoured surface of the seat and back supports the natural curvature of Samantha's spine. The lateral head and trunk supports help Samantha to maintain neutral head and trunk alignment.
-Attachment straps- One set of attachment straps are used to secure the Sitter to the mobile base. The attachment straps are also used to secure the Sitter on a standard chair in the community, home, or school. The straps allow the Sitter to be utilized in various environments, thus eliminating the need for multiple pieces of costly equipment.
-Mobile Tilt Wedge Base- Tilt in space positioning is essential for Samantha when she eats and receives some of her therapies. Samantha's head falls forward or to the side when she sits upright for greater than a few seconds. The tilt wedge base allows Samantha to be tilted 0 to 25 degrees from a vertical position. With the tilt wedge base, the Sitter is positioned near the floor so Samantha can interact with her peers and siblings who often engage in floor play.
Depending on the specific situation, you may also want to include what other equipment was tried and the reason that it did not help your client. It may also be helpful to include a picture of the Special Tomato Soft-Touch Sitter with Mobile Tilt Wedge Base.
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
Sample Letter of Medical Necessity for Special Tomato® MPS
February 24, 2003
Any Insurance Company
123 Any Street
Any City, Any State 12345
Re: John Smith
ID #: 123-45-6789
Diagnosis: Cerebral Palsy
To Whom It May Concern:
John Smith is a 2-year-old boy with Gross Motor Developmental Disabilities. John has good head control when his trunk is supported. John needs assistance to sit due to his limited voluntary control over his leg, trunk and arm muscles as well as high muscle tone throughout his trunk and extremities. As John grows, his positioning needs will change as well. The Special Tomato Multi-Positioning Seat (MPS)Size Small provides up to six years of growth along with the capability to adjust to accommodate John's changing positioning needs.
For John to concentrate on learning other tasks (i.e. speaking, listening to stories, watching other children, etc.), he needs to be in a fully supported sitting position. The Special Tomato™ MPS is recommended to provide proper sitting positioning for John. When John was evaluated in this system, he was able to maintain his sitting position without hyper-extending his hips, knees, and ankles.
The Seat Shell consists of a firm base to provide support for positioning John. There are three soft, flexible cushions that give lateral support to the head, trunk and legs. The cushions are covered with a material that is impermeable to fluids, making clean up easy and extending the life of the seating system.
The MPS has been crash-tested as a Car Seat based on FMVSS 213. The seat portion of the MPS can be place in a vehicle to provide John with the support he needs while traveling as well.
The Seat Cushion has HipFlex™. This feature allows for positioning of John's pelvis at the exact angle needed. The hips can be adjusted between 15° degrees of hip flexion to 15° degrees of hip extension. As John's abilities improve and change, this seating system can accommodate those changes to provide the best support for him.
The Footrest is adjustable in three dimensions: height depth and angle adjustable to accommodate growth and changing positioning needs. A 5-Point Positioning Belt provides complete positioning of the pelvis and trunk as well as adding safety.
The Attachment Straps allow the Special Tomato MPS to be attached securely to several different bases. The Attachment Straps can strap the Special Tomato MPS to most typical chairs found at his kitchen table, community center, local restaurant so that John can have proper positioning wherever he goes.
The Optional Special Tomato MPS Mobile Floor Base has locking swivel casters that will allow John to be transferred from room to room at his home or school safely without compromising his positioning. The Mobile Floor Base allows for up to 25° degrees of tilt-in-space to place John at the correct angle for a variety of activities.
The Optional Special Tomato MPS Push Chair Base accommodates the Special Tomato MPS. This stroller base has successfully passed the ANSI/RESNA WC/19 regulations for transportation using a 5-point tie-down system. John will need a transportable stroller to attend Pre-School in 10 months. John's family is having a lift installed in their van to transport John in an approved stroller system to take him to various therapy and doctor appointments.
The Optional Special Tomato MPS Tray is needed for upper extremity development. The tray provides a stable base for John to bear weight to develop strength and control in his shoulders and arms. The tray also provides a surface for a variety of activities for John (i.e. tactile activities, visual activities, mealtimes, etc.). It has 60° degrees of tilt that is easily adjusted to meet the needs of various activities.
The Optional Special Tomato MPS Seat Depth Extension Cushion is needed to provide the full 6 years of growth capability specifically for hip width and thigh depth. The Trunk and Head Cushions have the full six-year growth capacity built in.
Thank you for taking the time to consider this equipment for John. The Special Tomato Multi-Positioning Seat Mobile Floor Kit and Optional Accessories 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.
Sue Johnson, PT