Wheeled Mobility Letter of Medical Necessity Form
*INDIVIDUAL’S NAME: / Janie Doe / *ID NUMBER: / 000000000

Member Information and Background

*1. /
Date of Birth (mm/dd/yyyy):
/ 00/00/0000
2. /
Date of Evaluation (mm/dd/yyyy):
/ 01/30/2014
*3. /
Address Line 1:
/ Superior Rehab Nursing Facility
Address Line 2:
/ 000 Main Street
City:
/ Anytown /
State:
/ CT /
Zip Code:
/ 00000
*4. /
Evaluation Location Address L1:
/ Superior Rehab Nursing Facility
Evaluation Location Address L 2:
/ 000 Main Street
Evaluation City:
/ Anytown /
Evaluation State:
/ CT /
Evaluation Zip Code:
/ 00000
5. /
Height:
/
5
/
FT
/

5

/

IN

/

Weight:

/ 148 / LBS
6. / Professionals Present: / Name / Credentials / Agency
Mary Otherapist / MS, OTR / Superior Rehab Nursing Facility
Jane Wondernurse / RN / Superior Rehab Nursing Facility
*7. / DME Provider Evaluator: / Jay Doe / ATP / ABC Wheelchair Company
8. / Not Required for SNF/ICF Residents
Caregiver/Family: / Present During Evaluation?
*9. / Prescribing Physician: / Johnney A. Doe, MD
*10. / Physician Phone Number: / 000-000-0000
*11. /

Physician Agency:

/ Internal Medicine Specialists, Inc

Physician Address:

/ 00000 Main Street

Physician City:

/ Anytown /

Physician State:

/ CT /

Physician Zip Code:

/ 000000
12. /

a. Primary Reason for Evaluation:

/ Initial Wheeled Mobility Device / b. Primary Issues Relating to DME
(explain in 12c): / Size
Replacement / Does not address current medical needs
Modification/Repairs / Does not address current functional needs

c. Other Pertinent Information; i.e., additional information from 12b, rationale for replacement vs. modification, repair history, other information regarding request:

/ N/A
13. /

General Description of DME Recommendation:

/ Invacare Solara 3G Tilt-in-Space wheelchair with Matrx PB Contoured back and High Profile ROHO seat cushion
*INDIVIDUAL’S NAME: / Janie Doe / *ID NUMBER: / 000000000

14.

/

DIAGNOSIS(ES), INCLUDING RECENT SURGERIES AND DATES OF SURGERIES

/

RECENT CHANGE IN MEDICAL STATUS

Right CVA with resulting Left hemiplegia, apraxia, and left side visual neglect (8/15/13) /

YES

see 14a /

NO

/

NA

Left CVA and MCA with resulting expressive aphasia (2009) /

YES

see 14a /

NO

/

NA

Hx of Hypertension, DM II, alcoholism, IV drug abuse /

YES

see 14a /

NO

/

NA

YES

see 14a /

NO

/

NA

YES

see 14a /

NO

/

NA

14a.

/

Explain recent change in medical condition and/or other relevant information including symptoms, treatments, interventions and medications:

/ Previously living at home before Right CVA; transferred from the hospital on 8/21/13
Baclofen pump insertion 4/15/2013 since oral medication ineffective to address spasticity and associated pain (see physician's note 4/01/2013)
15. /

How will the person’s anticipated medical changes be accommodated in the requested Wheeled Mobility Device?

/ The requested Wheeled Mobility Device can be modified to meet anticipated medical needs.
Other
The specified wheelchair frame can be modified since it is a modular frame. The seating components can be modified or additions can be made if/when the patient's medical status changes or to address wear and tear issues.

16. Caretaker Support: The individual has 24 Hour Care.

16a. /

Caretaker Support Hours per Day:

/ 1 – 3 Hours / Relationship/Role:
3 – 10 Hours
> 10 Hours
N/A
16b. / Amount of Time Alone per Day: / 1 – 3 Hours
3 – 10 Hours
10 Hours
N/A

17. Additional Information:

N/A
*INDIVIDUAL’S NAME: / Janie Doe / *ID NUMBER: / 000000000

*18. List all Current/Previous DME:

DME TYPE, INCLUDING MANUFACTURER
AND MODEL / DATE OF PURCHASE
(MM/YY) / ENVIRONMENTS WHERE USED
(SELECT ALL
THAT APPLY) / IS DME CURRENTLY BEING USED? / IF INEFFECTIVE,
PROVIDE REASON / SKILL LEVEL
(CHECK ALL THAT APPLY)
18A. / Rolling Walker / 2009 / Home / YES / unable to use since R CVA in 08/2013; was previously used at home / Independent
Guardian / Work / NO / WNL endurance and distance
School / N/A / Below normal endurance and distance
Community / Dependent
SNF/ICF / Other:
Comments, including special features (e.g., specialty seating components or electronics):
Ownership: / Personally Owned / Other
18B. / wheelchair / >? 5 yrs old / Home / YES / sizing is incorrect; unable to provide adequate support since it lacks tilt-in-space feature / Independent
Drive Medical Tracer IV upright lightweight / Work / NO / WNL endurance and distance
School / N/A / Below normal endurance and distance
Community / Dependent
SNF/ICF / Other:
Comments, including special features (e.g., specialty seating components or electronics): / This therapist added seating components; however, frame modifications are not permitted by the nursing facility and the seating additions are inadequate to address her seating needs. It is not possible to address Ms. Simmon's postural needs in this wheelchair since she is unable to attain or sustain her trunk and head position without the assistance of gravity. A Geri-Recliner was trialed but was ineffective due to hamstring ROM musculature deficits.
Ownership: / Personally Owned / Other This wheelchair is owned by the nursing facility.
18C. / shower chair / 2010 / Home / YES / effective; used by many residents / Independent
Duralife tilt in space shower chair / Work / NO / WNL endurance and distance
School / N/A / Below normal endurance and distance
Community / Dependent
SNF/ICF / Other:
Comments, including special features (e.g., specialty seating components or electronics):
Ownership: / Personally Owned / Other This shower chair is owned by the nursing faciity.
18D. / Home / YES / Independent
Work / NO / WNL endurance and distance
School / N/A / Below normal endurance and distance
Community / Dependent
SNF/ICF / Other:
Comments, including special features (e.g., specialty seating components or electronics):
Ownership: / Personally Owned / Other
*INDIVIDUAL’S NAME: / Janie Doe / *ID NUMBER: / 000000000

19. Functional Skills

ACTIVITY / LEVEL OF INDEPENDENCE / DME USED TO ADDRESS FUNCTIONAL TASK / COMMMENTS/FUNCTIONAL CONSIDERATIONS
FOR REQUESTED DME:
Bathing / Independent / Mod Assistance / Provide number from DME list on page 3: / 18c / requires head and trunk postural components in tilted shower chair
Supervision / Max Assistance
Min Assistance / Dependent
Dressing / Independent / Mod Assistance / Provide number from DME list on page 3:
Supervision / Max Assistance
Min Assistance / Dependent
Grooming / Independent / Mod Assistance / Provide number from DME list on page 3:
Supervision / Max Assistance
Min Assistance / Dependent
Eating / Independent / Mod Assistance / Provide number from DME list on page 3: / 18b / G-Tube feedings; aspiration risks and precautions taken; in process of obtaining dysphagia assessment for possible oral feeding
Supervision / Max Assistance
Min Assistance / Dependent
Toileting / Independent / Mod Assistance / Provide number from DME list on page 3:
Supervision / Max Assistance
Min Assistance / Dependent
In-home mobility / Independent / Mod Assistance / Provide number from DME list on page 3: / 18b / see comments 18b
Supervision / Max Assistance
Min Assistance / Dependent

20. Orthosis(es)/Prosthesis(es): NA / None

ITEM / LEFT / RIGHT / BOTH / EFFECTIVENESS / COMMENTS/IF INEFFECTIVE, PLEASE EXPLAIN
Ankle Foot Orthosis(es) / Effective
Ineffective
NA / None
Knee-Ankle-Foot Orthosis(es) / Effective
Ineffective
NA / None
Below Knee Prosthesis(es) / Effective
Ineffective
NA / None
Above Knee Prosthesis(es) / Effective
Ineffective
NA / None
TLSO / N/A / Effective
Ineffective
NA / None
LSO / N/A / Effective
Ineffective
NA / None
Other: / Effective
Ineffective
NA / None
*INDIVIDUAL’S NAME: / Janie Doe / *ID NUMBER: / 000000000

21. Transfer skills: Independent for all transfers Dependent for all transfers Varied transfer skills; see completed table

FROM / TO / METHOD / LEVEL OF INDEPENDENCE / EQUIPMENT
Bed / Bed / Stand pivot / Independent / None
Wheeled Mobility Device / Wheeled Mobility Device / 1 Person Lift / Supervision / Mechanical Lift
Chair / Chair / 2 Person Lift / Min Assistance / Ambulation Aide
Hygiene Equipment / Hygiene Equipment / 2 persons using mech. lift / Mod Assistance / Sliding Board
from all locations / to all locations / Max Assistance
Dependent
Bed / Bed / Stand pivot / Independent / None
Wheeled Mobility Device / Wheeled Mobility Device / 1 Person Lift / Supervision / Mechanical Lift
Chair / Chair / 2 Person Lift / Min Assistance / Ambulation Aide
Hygiene Equipment / Hygiene Equipment / Mod Assistance / Sliding Board
Max Assistance
Dependent
Bed / Bed / Stand pivot / Independent / None
Wheeled Mobility Device / Wheeled Mobility Device / 1 Person Lift / Supervision / Mechanical Lift
Chair / Chair / 2 Person Lift / Min Assistance / Ambulation Aide
Hygiene Equipment / Hygiene Equipment / Mod Assistance / Sliding Board
Max Assistance
Dependent
Bed / Bed / Stand pivot / Independent / None
Wheeled Mobility Device / Wheeled Mobility Device / 1 Person Lift / Supervision / Mechanical Lift
Chair / Chair / 2 Person Lift / Min Assistance / Ambulation Aide
Hygiene Equipment / Hygiene Equipment / Mod Assistance / Sliding Board
Max Assistance
Dependent

22. Ambulation skills: Non-ambulatory on all surfaces Ambulatory on all surfaces Varied ambulation skills; see completed table

SURFACE / AMBULATION STATUS / SPEED / DISTANCE / ENDURANCE / BALANCE / SPECIFY AMBULATION AIDE
Carpet: / Ambulatory / WNL / < 10 ft / < 5 min / WNL / N/A
Non-Ambulatory / Slow / 10 – 30 ft / 5 – 10 min / Mild Impairment
Fast / 30 – 100 ft / 10 – 30 min / Mod Impairment
> 100 ft / > 30 min / Severe Impairment
Smooth: / Ambulatory / WNL / < 10 ft / < 5 min / WNL / N/A
Non-Ambulatory / Slow / 10 – 30 ft / 5 – 10 min / Mild Impairment
Fast / 30 – 100 ft / 20 – 30 min / Mod Impairment
> 100 ft / > 30 min / Severe Impairment
Varied
Terrain: / Ambulatory / WNL / < 10 ft / < 5 min / WNL / N/A
Non-Ambulatory / Slow / 10 – 30 ft / 5 – 10 min / Mild Impairment
Fast / 30 – 100 ft / 20 – 30 min / Mod Impairment
> 100 feet / > 30 min / Severe Impairment
Stairs: / Ambulatory / WNL / < 10 ft / < 5 min / WNL / N/A
Non-Ambulatory / Slow / 10 – 30 ft / 5 – 10 min / Mild Impairment
Fast / 30 – 100 ft / 20 – 30 min / Mod Impairment
> 100 ft / > 30 min / Severe Impairment

23. Describe conditions which impact person’s ability to ambulate and/or transfer safely, independently, and in a timely manner;
e.g., weakness, cardiovascular/respiratory compromise, ROM deficits, imbalance, tone, cognitive deficits, coordination, sensory deficits:

global weakness and tonal deficits, severe cognitive impairment
*INDIVIDUAL’S NAME: / Janie Doe / *ID NUMBER: / 000000000
24. Postural Control, Muscle Strength, and tone (Medical Research Council [MRC] Scale for Muscle Strength)
STRENGTH / ( + ) / ( - ) / ( + ) / ( - ) / TONE / COMMENTS
Trunk: / WNL (5) / () / Trace (1) / () / Hypotonia/Flaccid / Rigidity / anterior trunk flexion & R thoracic leaning; trunk rotation noted w/ L side posterior of R side
Good (4) / () / Absent (0) / () / Dystonia / Mixed Tone
Fair (3) / () / () / Spasticity
Poor (2) / ()
Right Upper Extremity: / WNL (5) / () / Trace (1) / () / Hypotonia/Flaccid / Rigidity / mild hypotonia
Good (4) / () / Absent (0) / () / Dystonia / Mixed Tone
Fair (3) / (+) / () / Spasticity
Poor (2) / ()
Left Upper Extremity: / WNL (5) / () / Trace (1) / () / Hypotonia/Flaccid / Rigidity
Good (4) / () / Absent (0) / () / Dystonia / Mixed Tone
Fair (3) / () / () / Spasticity
Poor (2) / ()
Right Lower Extremity: / WNL (5) / () / Trace (1) / () / Hypotonia/Flaccid / Rigidity / intermittent clonus noted with positional changes
Good (4) / () / Absent (0) / () / Dystonia / Mixed Tone
Fair (3) / (-) / () / Spasticity
Poor (2) / ()
Left Lower Extremity: / WNL (5) / () / Trace (1) / () / Hypotonia/Flaccid / Rigidity
Good (4) / () / Absent (0) / () / Dystonia / Mixed Tone
Fair (3) / () / () / Spasticity
Poor (2) / ()
Head/Neck: / WNL (5) / () / Trace (1) / () / Hypotonia/Flaccid / Rigidity
Good (4) / () / Absent (0) / () / Dystonia / Mixed Tone
Fair (3) / () / () / Spasticity
Poor (2) / ()

25. Postural Alignment of trunk, pelvis, neck, and lower extremities

POSTURAL ALIGNMENT / FIXED VS. FLEXIBLE / COMMENTS, INCLUDING QUANTITATIVE DATA
Trunk/Spine: / Alignment WNL / Lordosis / Fixed / high risk of fixed deformity without adequate positioning
Scoliosis / Rotation / Flexible
Kyphosis / Mixed/Other
Pelvis/Hips: / Even / Pelvic Obliquity Lower on Right / Fixed / tendency to sit with B LEs in position of abduction/external rotation for stability
Posterior Pelvic Tilt / Pelvic Obliquity Lower On Left / Flexible
Anterior Pelvic Tilt / WNL
Right Anterior Rotation
Left Anterior Rotation
Head/Neck: / Normal / Rotated Right / Fixed / left lateral neck tilt/flexion with rotation
Tilted Left / Anterior / Flexible
Tilted Right / Flat Lordotic Curve
Rotated Left
Leg Length: / Even / Discrepancy / Fixed
Flexible
Ankles/
Foot/Toes: / Even / Pes Cavus / Fixed / B ankle hyperpronation (Right foot > left foot)
Tibial Torsion / Hyperpronation / Flexible
Varus Heels / Hallux Valgus
Valgus Heels / Plantar-Flexed First Ray
Pes Planus / Hammer Toes
Other Pertinent Information: / SEE ATTACHED PHOTOGRAPHS SUBMITTED THROUGH CLEAR COVERAGE
*INDIVIDUAL’S NAME: / Janie Doe / *ID NUMBER: / 000000000

26. Coordination, Motor Control, and Balance