Statement of
Medical Necessity and Equipment Justification
(This page is obsolete and will be
replaced with data about my powerchair soon!)
Date of assessment: 10/1/07
Date of quote: 9/25/07 (prices not final get dealer
price)
Patient's name: Alin
D.O.B.: 8/8/91 Age: 16 years, 3 months
Medical diagnosis's: neuromuscular degenerative disease
NOS, sensory integration/processing disabilities,
Scheuermann's kyphosis, scoliosis, hypotonic
arms/trunk/neck, hypertonic legs, spastic legs,
seizures NOS, autism NOS,
Medical Considerations/History
Alin is currently medically unstable, his condition is
currently declining; he is functionally bedridden as he
cannot walk at all without assistance and with
assistance can only walk under 10 feet. His condition
has not showed any ability to regenerate.
Motor Observation
Reflexes and Abnormal Muscle Tone:
Alin exhibits low tone in his arms, trunk, and neck.
The low tone of the trunk compromises positioning and
posture when not supported correctly. Hypertonia of the
legs creates unprovoked constant muscle pain and other
symptoms. When excited muscle tone may increase but
usually drops back to original state before movement
occurs. He also exhibits severe hyperreflexia in his
legs which is attributed to the disease. He also
exhibits other abnormal reflexes.
Range of Motion/Motor Strength:
Alins control of active range is variably limited
depending on factors like fatigue and neurological
condition that day and other factors. Manual muscle
testing cannot be adequately performed on any
individual with hypotonicity or hypertonicity; an
observational evaluation indicates that Alin has
severely low muscle strength and stamina. Power and
coordination are variably below normal.
Voluntary, Isolated, Controlled Movements:
Alin has impaired movement across the board, voluntary
movement, isolated movement, and controlled movements
are variably impaired, depending on factors like
fatigue and neurological condition that day and other
factors.
Posture:
Alin exhibits severe postural problems, problems are
due to his neurological condition creating inability to
manage/sense own posture without assistance in
positioning along with muscular problems. He has a
severe progressive kyphosis with moderate progressive
scoliosis, when seated his back automatically curves
unless properly supported, his back does not exhibit as
severe an automatic curve when sitting in a tilted
state, as the angle of tilt increases the curve
decreases. His head also has severe support issues due
to hypotonia of his neck muscles, his neck muscles get
tired very quickly, as of right now he uses his arm to
hold up his head when his neck is fatigued.
Sensory-Motor Patterns and Processing:
Alin has hypersensitive sensation, the hypersensitivity
results in slight elation with good sensations and
crabbiness and erratic behavior with sensation he does
not like, he is aware of some body postures but this
awareness is highly variable; he appears to have some
apraxia. He lacks functional equilibrium and righting
reaction and falls over easily. A very noticeable
"rocking" motion is present unless sitting in a tilted
state, this is attributed to the sensory
integration/processing disability, in the last year
this has become worse. Powered mobility for Alin
itself, controlled independently would assist in
development of his motor skills, and sociological
skills as he would have independence, with proper
seating his other conditions (kyphosis and scoliosis)
can be slowed, halted and or improved, function can
also be increased through the use of a correct seating
system.
Current Seating
Alin is currently seated in a companion chair that mom
pushes for him, there is no adaptive seating being
used, his current seating is actually uncomfortable for
him and does not create any benefit except for
increased DEPENDANT mobility. When seated in his
companion chair his posture is severely abnormal due to
the lack of support. The back curve is severe and is
continuing to progress. Along with the abnormal
posture, his extremities are more painful and exhibit
more spasticity and hypersensitivity than usual. His
hypertonia is also notably increased. Motor function
across the board is further impaired in his companion
chair. There is also a notable increase in his
irritability due to the bad sensory
integration/processing exacerbation created. His
current seating is no longer viable due to his
declining condition and the lack of independent
mobility making physically going to school impossible;
powered mobility with custom upgrades is required due
to his declining condition.
Specific Recommendation's
The Invacare TDX-SP would be the most suitable power
base to meet Alins needs. The electronics allow easy
expansion of controls and if needed alternative switch
access. The TDX-SP also exhibits very good battery
range and has very good records of reliability. The
TDX-SP has all five of the Total Driving Xperience
technologies, justification for the technologies is as
follows. SureStep Suspension is required as Alin will
be using the powerchair for full time mobility indoors
and outdoors including in buildings with unmodified
thresholds. MK5-6 electronics allow Alin a centralized
control system to control his tilt system, and have
multiple "drives" allowing Alin to have a drive
programmed for at home, school, work, and outside.
Center Wheel Drive is an absolute requirement with Alin
as he does not have proper sensory
integration/processing abilities to accommodate for any
turning wideness, he requires the ability to turn on
the spot and be highly maneuverable, this is also
required as he will be primarily using his powerchair
in indoor environment. Stability Lock is highly
recommended as a safety when there is any tilt system
being used as Alin does not have the perceptual
processing to process what angles would become unsafe
for him to drive in, therefore, a pre programmed
mechanical "stop" is necessary. The TDX-SP is also
required as it can accommodate high end seating systems
and a tilt system. COST 6,000
Tilt system is required as Alin has very limited weight
shifting and readjustment abilities, he also just falls
into whatever position he is mechanically placed in, a
powered tilt system would allow totally independent
mobility and positioning control to improve stamina,
function, and comfort. Highly noticeable general motor
and swallowing function improvements are noted when
Alin is in a tilted state; therefore, it is likely that
the tilt system will be left at a small (<15 degree)
tilt at all times to allow proper "fall in" in his
posture ("fall in" meaning Alin will not have to hold
himself up as he will be completely externally
supported to allow better energy usage) COST 5,500
Stealth Comfort plus 10" headrest will provide proper
head support, and is required for several reasons,
Alin's head support issues would be mitigated. Alin's
constant tilt axis requirement requires that Alin have
some sort of external head support. (MUST BE ORDERED ON
PINDOT ORDER FORM) COST 500.00
"airline" seatbelt to provide safety at all times and
to allow Alin to ride in vehicles right in his
powerchair. Transfers to ride in vehicles are
unneccesary and would compromise Alins support systems,
and could create a safety risk if transfer failure is
to occur "airline" seatbelt is the easiest and simplest
method for him and his caretaker to use. COST 50.00
Transport Brackets to allow Alin to ride in vehicles
right in his powerchair. Transfers for vehicle
transport are unnecessary and would compromise Alins
support systems, and create a safety risk if transfer
failure is to occur. (willing to pay out of pocket)
COST 250.00
MPJ Multi Drive Joystick is required to allow Alin to
control his tilt system right from his joystick and
have the multiple drives he requires as stated in the
TDX5 base justification. COST 750.00
Quad Link Retract Joystick Mount MPJ Plus is required
as Alin needs to be able to move the joystick out of
the way to get as close as possible to desks and
tables. It is also required since the doors in the
house are not wide enough to have a statically mounted
joystick.
COST 279.00
Group 24 Batteries are required as Alin will be in his
powerchair full time and will require long-range
between charges. (willing to pay out of pocket) COST
410.00
Contour U custom seating is required as Alin requires
full external postural support and has complex seating
needs due to spinal deformities and high susceptibility
to further deformation from incorrect support systems,
a fully custom support system would completely
eliminate the risk for further degeneration of his
current deformities and may even be able to help with
improvement of the current deformities. It is also the
only known seating system to not exacerbate Alin's
sensory integration/processing disabilities. Contour U
custom seating would allow improved positioning,
stamina, function, and comfort. COST UP TO 2,000
Swing-away footrests and heel loops/ankle straps are
required for Alin's situation, Swing-away footrests
would allow for easier transfers. heel loops and ankle
straps are considered due to alin's bad leg control
which would likely lead to his feet falling off the
back of his footrests, the ankle straps are necessary
for when his leg spasms could become dangerous to him
or the environment and also will allow for better
control over positioning.
COST 56.00
Daessy laptop mount is needed as Alin will be full time
in his powerchair and desks in the house are not
roll-under accessible thus making using a computer on a
desk inviable, also with Alins constant tilt axis
requirement using accessible desks would not be viable
due to the need to be sitting up straight to use a roll
under desk; therefore, it is required that he has his
computer mounted. He also needs his laptop to be
wherever he is as it is his only way of communicating
other than verbally, no productivity is gained without
the laptop. COST 1000.00
Chest harnessing is required as alin has very low trunk
muscle tone and very bad self positioning abilities.
COST UP TO 500.00
TOTAL COST 19,000ish
Primary Uses of powered mobility equipment
If Alin receives powered mobility equipment it will be
used for independent full-time mobility and assist Alin
with proper positioning and be conducive to his other
conditions, with the powered mobility equipment going
to school would become possible again, as right now it
is impossible and he is currently on home bound
education program. This creates a negative benefit for
him sociologically as he has no outside interaction,
interaction is limited to online interaction through
his computer; with powered mobility he would be able to
physically go places and interact with people
independently.