medical necessity letter

Patient name:                        Willow Kirkland

DOB:                                    03/02/1995

Diagnosis:                        closed spiral fracture of shaft of left femur

ICD:                                    821.01

Date:                                    April 29, 2010

To Whom it May Concern,

This letter serves as a request and clinical justification for Willow to obtain an Invacare MVP Ultralight Custom Folding Wheelchair. Willow is an outgoing, energetic active fifteen-year-old freshman female at Valparaiso High School. She is currently attending art, band, cooking, engineering, and gymnastics. Her prior high level of function and activity requires Willow to ambulate great distances throughout her school and community on a wide variety of surfaces and environments. An appropriate wheelchair is crucial to her continued success academically as well scholastically and socially. Willow is 68 inches tall and weighs 130 pounds.

Willow’s medical history shows no past or future surgeries or diseases. Willow’s weight, cardiovascular, pulmonary, respiratory, integumentary and neurological status and function are within normal limits. Willow is left - handed. Other than the present injury, her skeletal and muscular status and function are within normal limits. She maintains good head control and her ROM of her upper extremities is within normal limits. She lives with her parents and two brothers in a two-story home in Valparaiso. Willow’s injury was sustained during a fall while skiing in Colorado on Spring Break.

Goals for wheelchair mobility:

Independence in the home, at school, and motor related ADL’s in the community.

Goals for seating system:

Optimize pressure distribution; provide support needed to facilitate function and safety; provide corrective forces to assist with maintaining or improving posture.

Wheelchair customizations:

Wheel locks: Willow’s bilateral elbow extension tested 5/5 on the MMT while maintaining a full 180’ AROM. Therefore, Willow’s upper extremities are strongest during extension. This strength dictates the wheel locks are to be engaged by pushing the lever on each side forward.

Pelvic positioning: Willow’s balance and postural awareness test measured 15/15 and requires a Velcro strap for pelvic positioning.

Caster wheels: Pneumatic caster wheel tires will allow Willow to ambulate a wide variety of surfaces. This will allow Willow to maintain her prior high level of activity in community, social, extracurricular events.

Wheels: Pneumatic treaded mag quick release drive wheels allow more traction on a wider variety of surfaces, reduce the potential for flat tires, and increase shock absorption. 

Quick release wheels: allow the chair to be lighter and smaller thus increasing the ease of maneuvering the wheelchair and continuance of independent ambulation. The quick release wheels also allow the wheels to be removed to decrease width for storage; and decrease weight for lifting.

Mag wheel style: increase propulsion ability.

Armrests: Removable wraparound armrests will allow easier performance of transfers and permit Willow to sit closer to her school’s CAD system and a wide variety of desks and tables. Willow’s classes in art, band, cooking, engineering and gymnastics require her to be able to accommodate a variety of desks and tables everyday thus increasing her level of independence.

Leg Rests: Front rigging of Willow’s wheelchair will be two legrests. Each legrest will have removable swing away footrests with pivot pins, calf pad supports with pivot pins, and swing away removable legrests with pivot pins. These will provide lower extremity support; maintain placement of foot on footplate; and decrease edema. Willow’s full leg cast requires support eight hours per day. The removable swing away rests allow for independent or assisted independent transfers.

Anti-tipping device: Willow’s wheelchair will have wheeled anti-tipping devices to prevent accidental backward tipping of the wheelchair. 

Seat cushion: Willow’s cushion will assist in neutralizing her lower extremities and increasing pressure distribution. An accompanying wedge will provide increased aggressiveness of seat shape to decrease sliding down in the seat.

Providing Willow with this wheelchair will allow for greater ROM, ease of transfer, longer distance ambulation resulting in increased independence in her ADL’s. If you have any questions, or are in need of additional information, please don’t hesitate to contact our office.

Thank you,

Jill Reiner, SPTA