Sample Letters of Medical Necessity
Assistive Device Date: To Whom It May Concern: I have been treating _____________________________________ for physical medicine and rehabilitation. This 60-year-old man suffers from polymyositis, recurrent aspiration pneumonia, and nasopharyngeal cancer. He demonstrates significant bilateral lower extremity weakness. He requires assistance to perform sit-to-stand movement for ambulation with a regular rolling walker. It would be medically appropriate and necessary for safety and independent mobility to have an Up n’ Free walker. This allows Mr. _____________________ to perform sit-to-stand activity without assistance and to ambulate independently for over 200 ft. It also allows decreased pressure on hi lower extremities, reducing the amount of recuravtum at his knees. This will prevent overstretching and deterioration of the knee joints. If you have further questions, please do not hesitate to contact me. Sincerely, _______________________________
Assistive Device Re: MR#: DOB: Date: To Whom It May Concern:
____________________ is a four-year-old female with a diagnosis of Cerebral Palsy. Due to weakness and tone abnormalities, she is unable to safely ambulate without an assistive device.
An Up n’ Free gait trainer by Easy Walking, with locking pins to lock rear wheels, has been prescribed which will provide appropriate assistance and will allow ______________________ to be as independent as possible during ambulation.
If you have any further questions, please contact me at __________________________________________________.
Sincerely, ___________________________________, M.D. ___________________________________, DPT, PCS, ATP
I am writing this letter, on behalf of XXXX, due to denial of a request for an Up n’ Free Walker. The following information will outline to the importance of Conner’s ambulation.
- Bone deterioration is a concern. Just like everything else, if they are not being used though weight bearing, they will lose their tone and become soft and brittle as time goes on. Walking will ensure that this will not become a problem for him.
- Spasticity is another issue. Spasticity occurs when, from the nonuse the ligaments and muscles in the legs, the joints begin to contract. The exercises that he does on a daily basis are simply not enough to address this problem.
- Spasticity restricts his range of motion and hampers his day to day living in simple things such as getting dressed and transferring in and out of his wheelchair. Assisted walking would promote the all important stretching effect that non-quadriplegics get every time they walk.
- In regard to the musculoskeletal system, it has been demonstrated that immobilization of muscle and lack of weight bearing on bones causes demineralization and true osteoporosis. This may cause pathological fractures. It may cause lose of bone calcium which also leads to deposition of calcium in the soft tissue and joints causing ankylosis or permanent fixation of the joint.
- Prolonged muscular mobilization has a direct effect on joints. Contractures of the joint capsule and surrounding muscles can cause restriction of the range of motion of the joint, lack of movement in the joints results in a lack of synovial fluid and will lead to irreversible degenerative changes in the joint cartilage.
It is not possible for XXXX to use a “standard walker” for ambulation due to a non-functional right hand/arm. For the above reasons, it would be detrimental to XXXX’s health to not be given the opportunity to ambulate using an Up n’ Free walker.
To Whom It May Concern, I am writing this letter with regard to __________ and the purchase of an Up n’ Free Gait Trainer. ________ is a ____ year old young woman whose complex medical and surgical conditions as well as her orthopedic and neurological deficits render her completely dependent in mobility. As a result of post-surgical complications and prolonged pain __________ has not walked in over one year. She currently is able to stand with a Kaye Walker for an average of 2-3 minutes with 1 Moderate Assist. Transfers are quite difficult, requiring 1 Maximum Assist to move to/from wheelchair, just going from sit to stand requires 1 Moderate Assist. The piece of equipment being requested would provide the needed support and assistance to allow __________ to safely and comfortably improve her endurance, strength and postural control necessary for progression to walking. The Up n’ Free Gait Trainer was used for a trial on __date__ with quite impressive results. While in the Up n’ Free, __________ was able to go from sitting to standing independently. She was able to stand with dramatically improved posture, and walk a distance of approximately 50 feet. She was able to sidestep, walk backwards and even do a modified lunge. All these activities were performed with only the assistance of the Gait Trainer and reported a significant decrease in the usual levels of pain she typically experiences with just standing and transferring. As you know, the medical importance of standing and weight bearing for orthopedic patients is well documented. The psychological benefits of improved posture, actually walking, the feeling of security provided as well as the reduction in pain experienced with the one time use of this device gives great hope for substantial improvement through its continued use. The specific pieces of equipment being recommended are: Up n’ Free Adult/Youth 8000-00-000 $3400.00 Standard Mobility Unit with one set of pistons (100 lbs.) with standard seating system As noted above, the Up n’ Free allows for increased safety to both __________ as well as her caregivers, in addition to increasing her actual capabilities. Additional Support Pistons 60 lb. set P/N 8000-10-002 $330.00 This accessory will provide __________ with progressively less support when__________ has improved to the point where she requires less assistance to stand and walk. Using this Gait Trainer daily for standing, walking, and strengthening will promote improved postural alignment, improved circulation, and stimulation of bone growth as well as incalculable improvement in self-esteem. The potential to increase ___________ independence cannot be overstated. __________ is an extremely intelligent young woman whose physical condition confines her, this device may well open avenues of self-sufficiency and independence which will be life changing. I urge you to allow __________the opportunity to safely, comfortably, and independently improve her condition. I believe the global benefits which ___________ will receive through use of the Up n’ Free Gait Trainer makes its purchase one of medical necessity. If you require any further information regarding the purchase of this stander please do not hesitate to contact me. Thank you for your assistance in obtaining for __________the equipment necessary to maximize her function.
March 17, 2008 To Whom It May Concern: The purpose of this letter is to highlight the differences between the “Up n’ Free” dynamic gait trainer and the standard gait trainer that has been approved for __________ as per the letter of denial dated February 28, 2008. ____________ is a 12 yo girl with a h/o seizure disorder and subsequent developmental delay. ____________ currently uses a Rifton standard gait trainer at school for weight bearing and gait activities. She does not have a gait trainer for home use. In January 2008, ________ was given a trial using an “Up n’ Free” gait trainer in our office by the designer and manufacturer “Easy Walking.” She responded very well to this dynamic gait training system with improved postural and LE alignment, control and endurance. The “Up n’ Free” gait trainer provided dynamic body weight support through the seating system that facilitated proper pelvic alignment and thus encouraged _______ to be more active in her trunk and LE’s to maintain an upright, weight bearing posture for a longer period time as compared to the standard Rifton gait trainer in which she “hangs” on the forearm support and does not maintain proper pelvis/ trunk and LE alignment and frequently “collapses” into the gait trainer. Similarly, the Up n’ Free’s dynamic hydraulic support system encourages ________ to be more active through her LE’s by pushing off the floor for sit<>stand transition as compared to the Rifton gait trainer in which she is placed in standing position only with no opportunities for LE strengthening with sit<>stand transitions. For gait training purposes, the Up n’ Free provides the opportunity for hands on facilitation through _________’s trunk and LE’s as she is well supported through the seating system as compared to the Rifton gait trainer in which the PT must keep hands ________’s forearms to maintain an upright posture with no opportunity for facilitation of proper lateral weight shifts or LE alignment. The Up n’ Free allows for more normal trunk rotation and freedom of movement creating more natural patterns of movement during the gait cycle. Finally, the cost of these two gait training devices is very comparable with the large Rifton Gait trainer with chest supports and arm prompts priced at $2195, and the Up n’ Free with additional chest support at $3400. The long term benefits of additional weight bearing, strengthening and dynamic gait training opportunities however, as outlined above, are dramatically different.