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Letter Of Medical Necessity – Chill-Out Chair

Date: To Whom It May Concern: I am the pediatrician for child’s name (DOB). Child’s name has the following diagnoses: Cerebral Palsy (ICD code) Secondary Diagnosis (ICD code) Third Diagnosis (ICD code) Fourth Diagnosis (ICD code) Additional Diagnoses added with qualifying ICD codes as required I am requesting an alternative seating device for child’s name given her complex and severe medical condition. Child’s name is nonverbal, has minimal communication and is fed exclusively through a feeding tube and is not mobile due to this severely limiting medical condition. The alternative seating device would be important for ideal head position and control and help with her muscle tone, something not available in any current seating situation. Child’s name is at risk for continued deterioration of her anti-gravity muscles, and bone development, as well as skin breakdown due to her immobility. This device would assist with these areas. This device would also assist child’s name with feeding and communication (by way of helping her with swallowing and respiration) which are severely impaired at this time and any help would be of benefit for child’s name and her parents. Given child’s name’s medical condition, I feel that this alternative seating device would be a huge medical benefit to this child and her family. If there are further questions or inquiries regarding this request, please do not hesitate to contact my office. Sincerely, Doctor’s signature and printed or typed name Doctor’s title and National Provider Identification...

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Letter of Medical Necessity – Adaptive Mobility Device

Date Re: Patient’s name DOB: To Whom It May Concern: Patient’s name is a 3 year-old male with a history of cerebral palsy, spastic dystonic quadriplegic type (ICD 343.9), with Gross Motor Function Classification Score of 4. Because of patient’s name’s condition, he cannot safely use regular mobility products. I am requesting a Freedom Concepts’ mobility device that is custom designed for his use. By providing patient’s name with an adaptive device, he can benefit from the use of this on a regular basis, providing him with therapeutic, reciprocal exercise with physical benefits such as strengthening muscles, improving range of motion, aiding circulation, developing hand/eye coordination and head and trunk control and improving endurance. Patient’s name is currently in PT, OT and ST. By adding this device to his therapy regimen, his therapeutic responsiveness will be enhanced. This adaptive mobility device provides a sense of individuality for patient’s name and he will benefit from peer interaction and social acceptance. I support the need for this therapeutic modality. If there is any additional information you need please do not hesitate to call_______________. Thank you, Sincerely, Physician’s name Title/ Professional Designations National Provider Identification...

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Justification Letter – Adaptive Mobility Device

Date To Whom It May Concern: My name is ________________________ and I am the Developmental Pediatric Practitioner at _________ and I am writing on behalf of my patient, _______________________. Patient’s name is a special young child with the following diagnoses: Chromosomal Anomalies (Cyclin-dependent Kinase-like 5 or CDKL5) 758.9, Autistic Disorder (299.0), Epilepsy and Recurrent Seizures (345.90) Asthma (493.90) Developmental Coordination Disorder (315.4) and Profound Intellectual Disabilities (318.2). Due to the above diagnoses, patient is severely limited in her mental and physical capabilities. The CDKL5 gene provides instruction for making a protein that is essential for normal brain function. One of the proteins targeted by the CDKL5 protein is MeCP2, which plays important roles in the function of nerve cells (neurons) and in the maintenance of connections (synapses) between neurons which affects the neurological and muscular systems in the body, causing gross developmental delay, seizures, mental retardation, and coordination disorders. Patient is currently receiving Speech Therapy and ABA therapy but is limited in physical activities due to developmental and coordination disorders/delays. Due to her limitation, patient would benefit from occupational therapy and physical therapy to help with physical conditioning, coordination, fine and gross motor skills. In addition, patient would benefit from an adaptive mobility device/aid to assist with physical conditioning, coordination skills and fine/gross motor skills. Research has proven that children who use an adaptive mobility device experience increased social interaction, increased improvement with fine/gross motor skill and performance in daily activities. I would appreciate your assistance in providing patient’s name with an adaptive mobility device. This device would help patient’s name benefit neurologically, physically and socially. In addition, an adaptive mobility device would provide patient’s name with a safe and effective form of physical exercise due to her extensive diagnoses/disabilities. Sincerely, Physician’s name Title/ Professional Designations National Provider Identification Number...

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Justification Letter – Adaptive Mobility Device

Date To Whom It May Concern; Patient’s name is a 9 year old girl who receives weekly physical therapy at ___________  for problems associated with her diagnosis of Left Hemiplegia Cerebral Palsy secondary to prematurity and a grade III IVH. Patient’s name was discharged from physical therapy with a shift to only a home program. Patient’s name plans to return to therapy during the summer break from school. Patient demonstrates a functional asymmetry, proximal muscle weakness, incomplete muscle gradation of her left side, joint and myofascial tissue restrictions on her left side, poor coordination of her left and right sides, and gait abnormalities. Patient underwent orthopedic surgery at ______  on______ to correct tibial torsion and heelcord releases. She was casted for 6 weeks then placed in bilateral articulating AFOs that were fabricated by ______________. With the shift to a home exercise program patient would benefit from an adaptive mobility device that she could independently use to gain further strength, lower extremity joint mobility, coordination of her left and right sides and endurance. It is medically recommended that patient’s name have an adaptive mobility device that would require her to utilize her LE muscles in a more active manner using an age appropriate piece of equipment. This mobility device, offered as a custom built product, by Freedom Concepts would be an excellent choice for patient’s home use. This device has been used for several months in her therapy program and patient has demonstrated safe independent usage. In addition to the medical needs being addressed, this device also promotes general fitness and offers patient’s name an opportunity to interact with her peers thus improving her participation in age appropriate social activities. Please consider the purchase of a mobility device that would meet patient’s name’s medical needs at this time. See attached detailed specifications for the appropriate mobility device and medical prescription. I can be contacted at __________ if you have any questions. Thank you for this consideration, Physician’s name Title/ Professional Designations National Provider Identification Number...

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