This page includes:
- Measurement Form
- Sample Vendor LMN Template
- Sample therapist LMN/documentation
- Washington State Medical Necessity for Wheelchair Purchase
1. Measurement Form
2. SAMPLE Vendor Letter of Medical Necessity Template
Name:
DOB:
Height:
Weight:
Insurance:
Insurance ID:
Referring Physician:
Signing Clinician:
Assistive Technology Professional:
WHEELCHAIR SEATING AND MOBILITY EVALUATION
MEDICAL HISTORY
Explain medical history/condition and why/how this indicates necessity of equipment. Delete this message.
REASON FOR UPDATE
Include the change in medical condition that resulted in the need for requested equipment. Discuss posture and positioning in current WC to illustrate deficits of current equipment. Delete this message.
CURRENT AMBULATORY AID
If current ambulatory aid is not being used, please indicate that this is the case. If currently using cane, walker or wheelchair, describe this equipment. Delete this message.
CURRENT SEATING AND WHEELED MOBILITY
Chair:
Age:
Wheelchair cushion:
Age:
Wheelchair Back:
HOME ENVIRONMENT
Type of home:
Entrance:
Wheelchair accessible rooms:
COGNITIVE/VISUAL/HEARING STATUS
Explain strengths and deficits in relation to wheelchair needs. Delete this message.
ADL STATUS
Pertinent ADLs include toileting, bathing, feeding, grooming, dressing and must be discussed in detail. Delete this message.
COMMUNITY ADL
BALANCE
Explain balance, ability to stand, ambulate and transfer in relation to need for wheelchair. Delete this message.
NEUROMUSCULAR
Document strength and ROM assessments in relation to need for wheelchair. Include any other pertinent neuromuscular assessments. Delete this message.
MOBILITY ASSISTIVE EQUIPMENT/ALGORITHM SUMMARY
Indicate Yes or No answer clearly by typing, bolding or circling Yes or No. Delete this message.
1. Is there a mobility limitation causing an inability of the user to safely participate in one or Mobility Related Activities of Daily Living (MRADLs) in a reasonable time frame? Yes / No
EXPLAIN:
2. Are there cognitive or sensory deficits (awareness/judgment/vision/etc.) that limit this user’s ability to safely participate in one or more MRADLs? Yes / No
EXPLAIN:
3. Does this user demonstrate the ability or potential ability and willingness to safely use the mobility assistive device? Yes / No
EXPLAIN:
For Tilt-In-Space, it is important to explain that CG is available to help client with safe use of the requested equipment. Delete this message.
4. Can the user’s mobility deficits be sufficiently resolved by using a cane or walker? Yes / No
EXPLAIN:
5. Does the user have sufficient function/ability to use a standard, lightweight, ultralight weight, or any other optimally configured manual wheelchair? Yes / No
EXPLAIN:
8. This user will need the recommended equipment for lifetime. Yes / No
EXPLAIN:
WHEELCHAIR TRIAL AND HOME ASSESSMENT
If patient is currently using a chair, explain why it is not meeting medical needs. If a MWC is not appropriate for trial, explain that as well. Delete this message.
RECOMMENDED MOBILITY BASE AND COMPONENTS
BASE:
Please edit this section as appropriate to your patient. Delete this message.
COMPONENTS:
Line item justification is required. Components may need to be added after our ATP completes his assessment. Delete this message.
Please do not type “electronically signed by….” Must be printed, signed and dated when complete. Delete this message.
_______________________________ ______________
Clinician Signature Date
I have read and concur with the above recommendations.
_______________________________ ______________
Physician Signature Date
Primary Care Physician: ***
Diagnosis: ***
3. SAMPLE Therapist Wheelchair Seating Clinic Report
Physical Therapy
Wheelchair Seating and Equipment Evaluation
| Encounter Information: |
Referring Provider: ***
Diagnosis: ***
Precautions: ***
Date of Evaluation: ***
Parents/Caregivers present: ***
Other Providers Present: *** (Vendors, etc)
Age: ***
Total Time: Start time: *** Stop time: ***
| Clinical Decision Making/Assessment: |
NAME is a AGE year old with ***. They require *** for mobility/transfers/gait etc. Wheelchair seating must support NAME in the most functional and least deforming position possible. An erect symmetrical pelvis with a straight erect spine and stable head are basic to these goals.
Recommended Therapy Follow-up:
To achieve the most efficient means of independent mobility, NAME will need the following equipment:
- Frame: ***
- Seat: ***
- Hip support: ***
- Back: ***
- Trunk Support: ***
- Seatbelt: ***
- Harness: ***
- Headrest: ***
- Armrests: ***
- Tray: ***
- Leg rests: ***
- Wheels: ***
- Brakes: ***
- Anti-tippers
Estimated Length of Time Equipment Will Be Needed:
99 years, lifetime
Estimated Length of Time Equipment Will Last:
3 years, depending on growth
| Plan of Care: |
***
Follow-up with PT 2 weeks after receiving wheelchair.
| History: *** |
Pertinent Medical History: ***
Present Seating: ***
Other Equipment: ***
Assistive Technology / Augmentative Communication Equipment: ***
Present During Visit:***
Home Environment: Adequate/Inadequate
Work/School Environment:Adequate/Inadequate
Transportation:Adequate/Inadequate
| Physical Examination: |
Range of Motion: Fully functional for sitting/Not functional for sitting
Muscle Tone: Increased/Decreased/Variable/No Concerns
Primitive Reflexes: Increased/Decreased/No Concerns
Protective / Righting: Absent/Present/Emerging
Skin Integrity: Good/Fair/Poor
| Seated Posture and Alignment: |
Pelvis:
Tilt: Posterior/Anterior/Neutral – Flexible/Structural
Obliquity: L/R Elevated/Normal- Flexible/Structural
Rotation: L/R Anterior/Normal- Flexible/Structural
Spine:
Scoliosis: Absent/Present – Flexible/Structural
Rib rotation: Absent/Present – Flexible/Structural
Curvature: Lordosis/Kyphosis/No Concerns– Flexible/Structural
Head:
Position: Midline/Tilted -Flexible/Structural
Hips:
Position: Abducted/Adducted/Neutral -Flexible/Structural
Deformity: None/L/R Windswept – Flexible/Structural
Feet:
Footplates: On/Off footplates
Typical footwear: ***
Upper Extremities:
Resting position: No Concerns/ Positioning BUEs in ***
Functional patterns/movement: No Concerns/ Tonic/ Fixing/ Ataxia/ Tremor/ Chorea/ Disorganized/ ***
| Functional Status: |
Head control: ***
Sitting balance – Short Sit: ***
Transfers: ***
Transitions: ***
Ambulation Device: ***
Ambulation Distance: ***
Ambulation Assistance: ***
Endurance: ***
| Seating Measurements: inches |
| Seat Depth | *** |
| Hip Width | *** |
| Shoulder Width | *** |
| Chest Width | *** |
| Seat to Axilla | *** |
| Seat to Shoulder | *** |
| Seat to Head | *** |
| Lower Leg Length | *** |
| Height | *** |
| Weight | *** lbs |
| Medical Necessity: |
Client is unable to walk and requires wheeled mobility over all surfaces. Without a wheelchair, client would be confined to bed. ***
| Prognosis: |
Prognosis is poor for independent ambulation. Prognosis is poor for healthy skin integrity without proper seating. Prognosis is excellent for independent propulsion.
Education: Discussed findings and recommendations. Family in agreement with plan. Provided this PT’s contact information for further questions or concerns. ***
4. Manual Wheelchair Form for Washington State Insurance
Pediatric Rehab Equipment 