Subject: Letter of Medical Necessity

(Date)

Subject: Letter of Medical Necessity Re: (Patient Name)

To Whom it may concern:

(Patient name) is a (Age) year old male who sustained a catastrophic paralyzing injury at (Level of Injury) and is an (ASIA Classification). (Patient name) was evaluated at (Hospital name) by staff whose practice and experience is focused exclusively on patients with spinal cord or brain injury. (Patient name) is paralyzed, with significant mobility limitations. As a result of his injuries (Patient name) has lost function in his arms or legs. The paralysis he has is a life long mobility limitation that has left him unable to perform mobility related activities of daily living [MRADL’s]. This patient's spinal cord injury has impaired his ability to use his extremities and impairs his ability to move about his environment. Due to (Patient name) disability he will require the use of this item for his lifetime. This item has been determined to be medically necessary.

Item: Spinergy ZX - 1

Justification: (Patient name) demonstrates decreased strength in bilateral upper extremities, including shoulder musculature and hand musculature. As such, when using a manual wheelchair, (Patient name) requires an increased number of push-strokes to go the same distance as compared to individuals without upper extremity impairment. By using increased number of push-strokes, significantly more stress is placed on (Patient name) shoulders, which will likely result in increased shoulder impairment and functional decline. If the aforementioned scenario occurs, (Patient name) will require significantly more assistance for functional mobility. Further, due to (Patient name) upper extremity impairments, he requires maxA for standard ADA ramp negotiation. In addition, as (Patient name) is employed as a college professor, this piece of equipment will allow (Patient name) to safely and efficiently negotiate his work environment, allowing him to negotiate hills and cross streets in a safe and timely manner. (Patient name) requires the use of power assistance to his manual chair to safely function in his environment.

As (Patient name) treating physical therapist who specializes in the treatment of patient’s recovering from spinal cord injury, I have reviewed the operation of this piece of equipment and acknowledge that (Patient name) is safe and capable of operating this assistive device.

These items are medically necessary due to (Patient name) neurological deficits and he, along with his treating staff, appreciate your assistance. Sincerely,

(MD name) Prescribing Practitioner Date

(Therapist Name) Prescribing Therapist Date