Equipment Letter of Justification
Primary Insurance Carrier: Equipment Vendor:
Attention: Medical Review/Authorization Primary Insurance Policy #:
Client’s Name: DOB: Height: inches Weight: lbs.
PCP: Secondary Insurance:
Rererring MD: Secondary Insurance Policy #:
(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 .
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
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 inches H inches
B inches I inches
C inches J 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:
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:
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
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.
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