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Equipment Letter of Justification - Pediatric Seminars Therapy Courses


									                                     Equipment Letter of Justification


Primary Insurance Carrier:                                     Equipment Vendor:
        Attention: Medical Review/Authorization                Primary Insurance Policy #:
        Insurance Address:
Client’s Name:                DOB:                   Height:           inches        Weight:        lbs.
Client’s Address:

PCP:                                       Secondary Insurance:
Rererring MD:                              Secondary Insurance Policy #:
Medical Diagnosis:
       (with onset date)
Provider Completing Evaluation:
Individuals Present During Evaluation:
           1.            Representing / Relationship to Recipient:
           2.            Representing / Relationship to Recipient:
           3.            Representing / Relationship to Recipient:
           4.            Representing / Relationship to Recipient:

To Whom It May Concern:

          is a          year old           with above mentioned medical diagnosis. This client was
evaluated by Northeast Rehabilitation Hospital Network Pediatric Equipment Clinic for the purposes of
determining medical need for           .

Personal Profile:
This section will describe dates and names of recent surgical procedures and/or hospitalizations as well as other
relevant information including medications, communication styles and general activity level. This client’s past
medical history includes            . This client lives with             in       ,           . This client’s
home is            . This client participates as part of their family by        .

Cognitive Status:         Self Aware      Others          Environment            Impaired      WNL

Vision Status:            Impaired        Corrected with device:                               WNL

Hearing Status:           Impaired        Corrected with device:                               WNL
Communication:            Verbal          Non Verbal               AAC          Impaired      WNL

Medical Status:         Stable            Fluctuating           Unstable
         Cardiovascular Status:          Normal          Impaired          Comments:
         Pulmonary Status:               Normal          Impaired          Comments:
         Bladder Function:               Continent       Incontinent       Comments:
         Bowel Function:                 Continent       Incontinent       Comments:


Comments: This client is active in their community through participation in           . There is need for this
client to access their community and medical resources on a           basis for the purposes of           .

Home, School & Community Environment:

This client participates in the following therapies:
School Therapies:         PT           x per wk          OT              x per wk      ST            x per wk
Home Therapies:           PT           x per wk          OT              x per wk      ST            x per wk
Outpatient Therapies:     PT           x per wk          OT              x per wk      ST            x per wk
Other Services:

Clinical Assessment:

This client presents with the following strength:
          Head & Neck Control:            WNL            Good            Fair          Poor           None
                 Trunk Control:           WNL            Good            Fair          Poor           None
     Upper Extremity Control:             WNL            Good            Fair          Poor           None
     Lower Extremity Control:             WNL            Good            Fair          Poor           None

This client presents with the following ROM restrictions:
                 Head & Neck:            WNL             Impaired    Comments:
                 Spine / Trunk:          WNL             Impaired    Comments:
             Upper Extremities:          WNL             Impaired    Comments:
             Lower Extremities:          WNL             Impaired    Comments:

Are any tone issues present with this client?          Yes      No If yes, please comment:

Are there any postural issues with this client? (include pelvis, neck and trunk)
                                              Yes     No If yes, please comment:

Brief description of this client’s motor control & coordination as it relates to upper and lower extremity
       function is as follows:            .

This client’s balance includes short sitting balance is     independent  with support &
        standing balance is       independent         with support. Comments:          .

Are there any Pain issues present with this client?          Yes      No If yes, please comment:
Are there any Skin Integrity issues present with this client?             Yes      No
         If yes, please comment:
         Client presents with the following skin integrity risk factors       None
                       impaired nutritional status                fecal or urinary incontinence
                       Compromised circulatory status             bony prominences
Equipment Measurements:                  Please refer to equipment measurements by vendor

    A                                                                                             I




                   A              inches                            H               inches
                   B              inches                            I              inches
                   C              inches                            J              inches
                   D              inches
                   E              inches
                   F              inches
                   G               inches

Functional Mobility & Transfer Status              Independent             Assisted                Dependent
This client is able to perform the following transfers:
          1. Client is able to perform bed mobility with                  level of assistance.
          2. Client is able to transfer in and out of a chair with           level of assistance.
          3. Client is able to transfer in and out of mobility device with             level of assistance.

Current mobility section will address client status as follows:
         1. The client would be confined to a bed if a wheelchair were not provided.
                                                                              Yes    No                    N/A
         2. The client is able to use a walker, cane or walk with assistance.
                                                                              Yes    No                    N/A
         3. The client is able to ambulate without assistance.
                           If yes… distance           feet                    Yes    No                    N/A
                                     Speed      functional        non-functional
                                     Balance      adequate for safe ambulation             unsafe
                                     Can client ambulate to all areas of the home?                  Yes       No
           4. The client is able to propel a manual WC without assistance.
                             If yes… distance            feet                              Yes      No        N/A

Comments (Description of client’s mobility limitation, method of mobility and level of assistance and how it
interferes with the performance of activities of daily living and access to home/ community):

Please check which conditions impact functional mobility for this client:
                 weakness            imbalance            fatigue / poor endurance
                 history of falls    lack of ROM          lack of coordination / motor skills
                 cognitive deficit   pain                 vision / hearing deficit
                 impaired judgment                        compromised respiratory status

Accessibility to this client’s environment is as follows:

Self Care / Provider Status / ADLs Status:           Independent            Assisted                Dependent

Client is reliant on their family for the following: (note safety risks, excessive time needed & level of assist)
            1. Bathing level of assist required
            2. Toileting level of assist required                     N/A
            3. Grooming level of assist required
            4. Dressing level of assist required
            5. Eating level of assist required                      N/A
            6. Food Preparation level of assist required                       N/A
            7. Other ADL Activity:                 level of assist required           .

This client is successful in and enjoys participation in the following activities:

Current Equipment: (Include in this section any equipment purchased or donated, braces / orthotics, home
      safety equipment, mobility / non mobility equipment, condition of equipment & age of the equipment.)
          1. Make:              Model:              Age:             Status:
          2. Make:              Model:              Age:             Status:
          3. Make:              Model:              Age:             Status:
          4. Make:              Model:              Age:             Status:
          5. Make:              Model:              Age:             Status:

    Yes       No This client has equipment that is in disrepair, ill fitting, poses safety concerns or is inadequate
                 to meet the child’s needs. Comments if yes:
Presenting Issues:

       This client was referred to the equipment clinic for evaluation of the requested equipment due to
          . This impairment impacts this client’s function and quality of life by          . This client was
evaluated and multiple pieces of equipment were considered including: (note less costly equipment and why
they would not be appropriate to meet this recipient’s needs.)
       1.            - equipment was not recommended because of                 .
       2.            - equipment was not recommended because of                 .
       3.            - equipment was not recommended because of                 .

Special considerations to note for this client include:            .

Requested Equipment with Justification for each piece:
         1.          Justification:
         2.          Justification:
         3.          Justification:
         4.          Justification:
         5.          Justification:
         6.          Justification:

    Yes       No The requested equipment is replacing a piece of equipment the recipient currently has.
                     If yes, explain:
    Yes       No The requested equipment is a duplication of a piece of equipment the recipient currently has.
                     If yes, explain:
    Yes       No The recipient has completed a trial of at least two (2) weeks with the recommended
                     equipment or a similar / simulated piece of equipment at home or school.
    Yes       No Alternative equipment options were considered. (Least Costly, Pwr vs. Manual,
                     multifunctional / multipurpose devices) Comments:

       Overall, the requested equipment will provide a variety of positional, functional and therapeutic gains
           Improve ability of client to participate in modified ADLs
           Reduce the incidence of skin break down
           Improve independent function
           Improve mobility
           Promote / improve alignment
           Accommodate / Slow progression of this client’s deformity
           Provide total body comfort / increase positional tolerance
           Improve sitting balance
           Improve standing balance

The unique features of this device include          . The requested equipment was simulated or trialed and
determined that it is medically necessary and most suitable for this client as noted above. The recommended
equipment (check all that apply):
           Will allow access, utilization and storage within client’s home.
           Will allow access to school / place of employment.
           Will meet van/bus/other transportation methods client currently needs.
           Will meet client’s mobility needs
           Potential growth of client has been taken into consideration in selecting the size of equipment so that it may
       provide at least five (5) years of use.
           Client’s caregivers are familiar with care/maintenance/operation of this equipment.
           Client has demonstrated proficiency the safe operation of this equipment.
           Less Costly equipment has been ruled out as inappropriate.
           This piece of equipment will accommodate the client’s additional medical equipment needed (ie. respiratory
       and enteral equipment) and other special needs.

       The family has demonstrated an understanding of the functionality and safety in using the recommended
device. The recommended device will suit the needs of the child and allow appropriate growth for use of this
device for          years. The expected frequency for the requested equipment to be used (per day/week &
how long per day/week) is          . Additional comments:

If you have any questions or concerns please contact this therapist or the Durable Medical Provider.

Thank You,

Medical Certification by Physician:

By signing this letter, the physician is certifying the medical necessity of the recommended piece of equipment
for this client. Further Comments by Physician: _______________
                                                               _____                               ____________

               Date                                              Physician’s Signature

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