Gait Trainer Letter Of Medical Necessity (Sample) printable pdf download

Gait Trainer Letter of Medical Necessity (Sample)

J.T.

Physician: Dr. T. Jones

123 Main Street

Therapist: B. Smith

Anywhere USA 12345

Insurance: Anthem BC/BS

(800) 555-2222

Policy #: 123456789

Secondary Insurance: Medicaid

Policy #: 987654321

DOB: 01/01/2005

Duration of Need: Lifetime

Diagnosis: Cerebral Palsy, Spastic Quadriplegia, Developmental Delay

Height: 4’10”

Weight: 73 lbs.

The following is medical necessity justification for a gait trainer for JT. JT is a 12 year old male with a

primary diagnosis of Cerebral Palsy since birth. JT is non ambulatory due to spasticity in all four

extremities and overall weakness. JT cannot sit without support. He currently uses a wheelchair with

contoured seating to provide him with the needed support throughout the day. JT is currently a student

at West Middle School in Anywhere USA. His communication is mostly non-verbal with gestures and a

communication device. JT can partially weight bear but requires maximum assistance to maintain his

balance.

I am JT’s primary school physical therapist. I see JT twice per week for physical therapy during school.

I have been working with JT for 3 years now. I have worked with children for 8 years both in the clinical

and school settings. I have recommended all types of rehabilitation equipment for clients over that

period of time including numerous adaptive walkers and gait trainers.

JT is currently confined to his wheelchair for the duration of the school day. At home JT is bed or

wheelchair confined. Currently he has no other device to use and he cannot be transferred to a

standard desk or chair. Prolonged sitting in his wheelchair is beginning to result in muscle tightness in

JT’s lower extremities. This puts JT at risk for flexion contractures. Additionally, JT is at risk for pressure

ulcers due to the amount of time he spends in the wheelchair, his inability to perform a weight shift, his

diagnoses, and compromised nutritional status. Because JT uses a tilt in space wheelchair, he is unable

to propel himself and therefore not independent in his mobility.

I am recommending that JT receive a Moxie GT gait trainer with bilateral forearm platforms, trunk

support, and hip positioner with pad. We have trialed the Moxie gait trainer with JT for 4 weeks during

his school therapy time. The Moxie provides JT with the necessary support of his pelvis via the hip

positioner with the pad. The trunk support provides both front to back and lateral stability for JT’s

trunk. Additionally, the trunk support can be angled in an anterior position that will help prompt JT to

take steps as he learns to ambulate. The bilateral forearm supports will provide an additional surface

Gait Trainer Letter Of Medical Necessity (Sample)