Overwhelmingly the first thing asked by the insurance companies, and really the only thing they want to know, is : What is the diagnosis code of the child?
Writing the story about the cerebral palsy with afflicted tone issues and spasticity in a nicely worded letter is expected but they also want what is called the ICD-9 code. That is the single most asked thing across the board and the very first thing they ask me when I call them.
We need to ensure that that is included in the letters.
Secondly, a letter from a PT or OT is fine but the insurance companies ask first and foremost for a letter from a physician ( or neurologist if applicable).
Third, they want a prescription, an actual prescription for a â€śtherapeutic mobility deviceâ€ť or â€śadapted mobility deviceâ€ť and it should be 1. Â signed by the physician who wrote the letter (or one of them if there are more than one physicians writing letters) 2. state the ICD-9 code on there AND 3. include the physicianâ€™s NPI number (National Provider Identification) if they have one.
Those are must haves for submitting to any of the major insurance providers such as Aetna, Blue Cross/Blue Shield, United Health Care and even some of the smaller ones.
This page includes a few examples of justification letters that successfully received funding. If you still have questions or concerns, please do not hesitate to give us a call at 1-800-661-9915 for further information.
The following insurance companies have recognized the therapeutic benefits of our mobility aids:
Here is an example of what a justification letter should include:
What, Who, How, Where?
A funding letter/letter of support should be in the form of a report.
Terms that are useful:
“Prevention of” or “accommodation to”.
For example: sores, contractures, orthopedic deformities
“Promote and/or support”
For example: breathing, swallowing, mobility
Refer to the three wheeled trike as a “therapeutic mobility device”.
The term to use is “adequate” not “optimal”. No product is ever “perfect”. It will not last forever because conditions of the patient and situation are constantly changing.
A Physician’s note to endorse the report is helpful.
Always use “patient” not “client”. It is a medical system, and the product is being funded for medical reasons. Physicians do not have clients.
It is imperative to define the product as a medical necessity. It is very specialized to the individual.
It is also very important to point out the long-term benefits. These benefits include:
- Bone Growth
- Strengthening of anti-gravity muscles
- Development of hand/eye coordination
- Opportunity for cognitive growth
- Respiratory activity
- Development of Head & Trunk control
- Social Acceptance
- Improved self-esteem
LETTER OF MEDICAL NECESSITY
To Whom This Concerns:
Name of patient is an adequate 5 year old who is followed in the Pediatric Regional Epilepsy Program for his chronic static encehalopathy secondary to a removal of a teratoma with VP shunt placement, resulting in right-sided hemiparsis. He also has an intractable seizure disorder.
He has been receiving physical therapy for his right-sided hemiparsis, and although this has been extremely helpful, it is not enough at this time. I am therefore, strongly recommending that Name of patient have a “Therapeutic Mobility Device”, to aid him in extension, and strengthening.
Signed by Pediatric Neurology Nurse and Pediatric Neurologist.
LETTER FROM A PEDIATRIC PHYSICAL THERAPIST AND A PEDIATRIC OCCUPATIONAL THERAPIST
To Whom It May Concern:
Name of patient is a 5-year-old boy who was born with cerebral teratoma. The tumor was surgically removed and a VP shunt was placed. Name of patient has also been diagnosed with a severe seizure disorder.
Name of patient is currently receiving physical and occupational therapy at Name Hospital and Medical Center. His clinical diagnosis is right hemiparsis. Name of patient presents with right upper and lower extremity passive and active range of motion limitations, moderately increased muscle tone of the right upper and lower extremities, delayed balance reactions, and severely delayed gross and fine motor skills.
To date, physical and occupational therapy has focused on increasing muscle strength, decreasing muscle tone, improving balance and coordination and facilitating age appropriate gross and fine motor skill acquisition.
This type of device mobility device would be an excellent adjunct to Name of patient therapy regimen. The mobility device would allow Name of patient to exercise at home, thus providing a program to maintain joint range of motion, increase muscle strength, and improve balance and coordination.
As Name of patient Physical and Occupational Therapists, we request that you consider the purchase of this type of mobility device. In our professional opinion we believe that it will assist in improving Name of patient functional skills. If you have questions don’t hesitate to contact us at phone number.
Pediatric Physical Therapist Pediatric Occupational Therapist
ANOTHER EXAMPLE OF A JUSTIFICATION LETTER
Name of patient is a thirteen-year-old boy with a diagnosis of cerebral palsy and global developmental delay. He is currently receiving psychological, occupational therapy, physiotherapy and speech language pathology services through Name of treatment center. He attends Name of school and where it is located where he is provided with a full time educational assistant. The educational assistant has been provided with programming suggestions including a daily physiotherapy program.
General upper limb strength is good and Name of patient is able to ambulate indoors or on level surfaces outdoors using a posterior Kaye walker and bilateral ankle foot orthoses. Gait abnormalities particularly a scissor gait with persistent hip and knee flexions during stance have been observed. He uses a wheelchair for longer distances within the community. Lower limb range of movement is significantly limited and tightness is especially noted in hip abductors, hamstrings and Tendo Achilles bilaterally.
Physiotherapy goals are to improve lower limb range of movement, increase lower limb functional strength, further develop balance and equilibrium reactions and improve gait pattern. It is felt that Name of patient would benefit from a mobility device other than his wheelchair that would address these goals in a functional manner. In addition to these specific goals a mobility device that requires Name of patient to utilize his muscles in a more active manner would promote general physical fitness and social development.
Direct physiotherapy intervention is only available once every three months. However, it is felt that Name of patient has the potential to progress further with regard to his physical development. Therefore, it is strongly recommended that such a piece of equipment be purchased for Name of patient.
ANOTHER EXAMPLE OF A JUSTIFICATION LETTER
Name of patient is a 20-year-old young woman with a diagnosis of cerebral palsy, visual impairment, and global developmental delay. I have known and been involved in physiotherapy intervention with Name of patient for nearly fourteen years. She presently attends Name of school and place where she is provided with a full time educational assistant. The educational assistant has been provided with programming suggestions including a daily physiotherapy program.
Name of patient ambulates with a rollator walker. She requires the use of a manual wheelchair for long distance mobility in the community. Her lower limbs range of movement and strength are limited by knee flexion contractures and tight hip flexors. Name of patient is on a long-term program of stretching, muscle strengthening, and using functional electrical stimulation to develop quadriceps strength. Over the years, she has required surgery for hamstring lengthening, and correction of foot position.
Physiotherapy goals are to maintain/improve lower limb range of movement, increase lower limb functional strength, and maintain independent mobility with a functional gait pattern. It is a long-term process to continually contest the effects of gravity on her gait and posture as she is constantly pulled down into a flexed, crouch gait.
In my opinion, Name of patient would benefit greatly from a wheeled mobility device such as an adult tricycle. In addition to addressing the specific goals of maintaining or improving range of movement, and increasing lower limb strength, a mobility device would also promote general physical fitness and social development. It would also provide a practical means of mobility within the community for longer distances, and allow her to participate actively in group outings. Name of patient has tried using a modified regular bicycle with limited success.
Freedom Concepts Inc. manufactures a tricycle that would meet Name of patient needs. The Discovery tricycle provides the necessary trunk support and ease of pedaling that Name of patient would require. The wide base would facilitate balance and mobility. This equipment can be adjusted for growth. It is anticipated that Name of patient could use this equipment outdoors within the community during the appropriate months of the year and then use the device at the school as an adjunct to her physiotherapy program over the winter. It is strongly recommended that this equipment be purchased for Name of patient.
ANOTHER EXAMPLE OF A JUSTIFICATION LETTER TO A NON-PROFIT
Dear Sir or Madam:
I am writing to ask the (name of non-profit) to support an important request that will greatly improve the quality of life of one seven year old boy. Name of patient has a rare syndrome referred to as Name of syndrome causing a severe developmental disability, seizure disorder, visual impairment, physical disability and swallowing disorder. We are requesting amount for the purchase of a Discovery Bicycle. This amazing bicycle is specifically designed for individuals with physical disabilities and each bike is constructed to meet the individual needs of the child.
Name of patient lives at home with his family in city and receives in home support from the Toronto Association for Community Living (name of organization). Since 1948, (name of organization) has provided service and support to over 5,000 adults and children with a developmental disability and their families. (Name of organization) goal is to ensure that persons with a developmental disability live in a state of dignity, share in all elements of living in their community and have equal opportunity to participate effectively.
Name of patient attends a school for children with severe disabilities. His pervasive disability affects all aspects of his development. He requires the use of a specialized wheelchair, can sit upright with support and can only consume liquids and some soft foods, ie. pudding. Name of patient is totally dependent on others to meet his basic needs. Name of patient enjoys standing upright and moving with the use of a walker inside for short periods. A Discovery Bike would greatly enhance his sense of mobility and freedom while outside. The bike would not only provide very beneficial physical therapy but greatly increase his presence within the community. Name of patient’s parents hope that the neighborhood children will see Name of patient in a “new light” (not one of total dependency but one of a kid just like them riding his bike).
Thank you very much for considering this request. If you require further information, please do not hesitate to contact me.
Home Management Consultant, TACL