Writing letters of justification and medical necessity for standers

By Ginnny Paleg, PT

Once upon a time, equipment vendors wrote our letters of justification for us and everything got paid. Today, it's a whole new world. Everything gets denied at least once. You have to write one letter and then another after you get denied. But there are some formulas you can use to avoid denials when requesting a stander. Here is a simple guide to writing such letters.

Essential Elements

Diagnoses and Description of the Child's Disability. Describe and explain (in relatively simple but complete terms) how the disability affects the child's ability to function in school, home and in the community. You must describe how the disabling condition(s) and/or functional limitation(s) necessitate the request for the stander.

Description of the Device (Stander). The stander requested should be described in some detail and compared and contrasted with other products on the market. Explain why you think this one is the best. Discuss what other models you tried and why they were not successful. Address price differences and explain why an expensive piece of equipment is worth it, or highlight that this piece is less expensive than other options. A successful trial of the exact item that you are requesting is a big bonus. A more thorough description is required when the equipment is new, unique, customized or not frequently requested.

If you are ordering a self-propelled or dynamic stander, sometimes it's best not to stress the mobility aspect of this stander because some third party payers are used to standers being stationary. They often confuse a standing mobility product with a sitting one (wheelchair) and will only fund a single mobility device.

Medical Necessity of a Stander. The letter should explain how the requested standing device addresses the requesting party's medical needs or functional limitations. Do not use any benefits to the caregiver as justification. The insurance is for the child and is not concerned about health care costs to the parent. Instead, cover increased pulmonary perfusion/clearance and decreased constipation.

Standing Is Standard of Care for Children. You should describe how the stander compensates for a function, which is limited as a result of a disability. It is also helpful to describe the medical benefits. Be sure to site relevant research articles.

Holoprosencephaly

The sample letter deals with a patient with a rare condition explained here to facilitate your understanding of specifics mentioned in the letter.

Holoprosencephaly is a rare (0.63-1/10,000 live births) developmental brain disorder that physical therapists may encounter in children with gross motor delays. Most individuals with this condition present clinically with severe cerebral palsy.

Holoprosencephaly results from failure of the embryonic forebrain to separate and the failure of the prosencephalon to cleave into the cerebral and lateral hemispheres. This defect occurs at approximately six to 10 weeks gestation.

Holoprosencephaly can be divided into three categories: alobar, semilobar and lobar, depending on the degree of cleavage. Alobar holoprosencephaly is the most severe form. Findings of this type include absence of the interhemispheric fissure, a single primitive ventricle, fused thalami, and absent third ventricle, olfactory bulbs and optic tracts. These children tend to have the most severe deficits.

Semilobar holoprosencephaly is characterized by partial separation of the cerebral hemispheres and a single ventricular cavity. In the most mild form, lobar holoprosencephaly, the interhemispheric fissure is well-developed but there is some fusion of structures. Individuals with lobar holoprosencephaly can be moderately affected to near normal.

Ginny Paleg is an NDT certified pediatric physical therapist. She is an adjunct faculty member and doctoral candidate at the University of Maryland in Baltimore. She teaches a continuing education course on standers and gait trainers. She can be contacted at gpaleg@hospsc.org

Sample Letter

Sample letter of medical justification of the necessity for a stander for a child with holoprosencephaly.

Child Name:____________________________

Date of Birth:________________________________

Date of Assessment/Letter:__________________________

Name of Physical Therapist:_____________________________

Address:_______________________________________________

Phone Number:_________________________

Email:_______________________________

Name of Physician:___________________________

Address:____________________________________

Phone Number:_____________________________

Email:____________________________________________

Emma is a 3-year-old with holoprosencephaly. She is currently functioning at the 7-month level for gross motor skills and 9-month level for cognitive function. Emma exhibits severe truncal hypotonia, which is typical for this diagnosis.

When she was placed with her foster (now adoptive) family, she was unable to hold her head up, roll, sit or reach. She was diagnosed with failure to thrive and had experienced multiple shunt failures. After g-tube peg placement, Emma was more alert and seemed to have the energy to begin to move.

When she was evaluated by her school physical therapist, she was observed to have scatter skills that made the PT try a more aggressive approach. Together, the classroom team and therapy team designed and implemented an educational routine that included sitting, standing and walking. Emma was placed in a regular classroom chair, stander and gait trainer at least once a day (each) for 20 minutes. While in these positions, the adults worked closely with Emma and facilitated functional skills. One year later, Emma has gained a full year of gross motor skills. Emma can now stand at a table x 15 seconds with arm support, perform sit to stand transfers with hands held only and take 10 reciprocal steps in a gait trainer.

Gait trainers may be used to help individuals with holoprosencephaly learn to stand and take steps.

The team recommends that it is now time to purchase Emma a stander for home use. Emma has functional range of motion at all joints but exhibits considerable extremity hypertonicity when she is excited and when she is ambulating. Manual Muscle Testing (MMT) is an inappropriate tool for Emma due to her tonal abnormalities, but it is often used as a guide in finding problem areas. She is assessed as having fair strength in quads and hip extensors since she kicks spontaneously in supine, makes stepping movements in supported standing, and moves the gait trainer forward for short (10') distances.

The major problem interfering with function appears to be truncal hypotonicity and weakness combined with the inability to gradate her extremity movements. Emma has low tone and fair muscle control at rest, but as she moves she overshoots into extension and often gets stuck there. If she can maintain her movements in mid-range, she demonstrates good control and is quite functional. Another problem is Emma's inability to control her pelvis, and her difficulty initiating knee and hip flexion.

Emma has been using a _______ stander for the past week. It was loaned to us by the vendor. Emma enjoys this model. She is able to lie flat when she is loaded, which decreases her anxiety. She tolerates the stretching of the abduction system well, and does not cry. This model fits her perfectly and she really enjoys doing her school work on the tray.

Emma needs to stand for 45 minutes every day to maintain bone density, stretch muscles, improve pulmonary clearance, decrease constipation, and learn to work against gravity (strengthening). There are many alternatives for Emma to practice standing. The ______ stander is the best option because it holds Emma's hips in abduction. This has been shown in studies to improve hip placement and decrease the need for multiple hip reconstruction. This is the only stander on the market with independent hip abduction adjustment.

She now stands at home by the side of a table or couch with contact guard and stands at school, with arms on a table for at least two five-minute periods. She is beginning to learn to be responsible for her own body weight. Her diaper is changed at least twice a day while Emma is standing. She practices at least five sit to stand transfers daily with hands held only.

Emma will continue to make functional gains if she is properly supported and provided with the adaptive equipment she needs in school and at home. School has provided Emma with the equipment she needs to be in the least restrictive environment. Her medical insurance should provide her this same opportunity at home to facilitate her medical improvement. Her mother reports decreased need for suppositories, decreased reflux and decreased missed school days due to respiratory infections when Emma uses her stander at school consistently. We hope to continue these improvements by increasing her time upright by having her stand at home as well.

Sincerely,

Name and signature of PT

Name and signature of MD