May 11, 2007

Letter of medical necessity for a power wheelchair

Re:  Robert Davis
DOB: 05/23/1919

To Whom it May Concern:

Mr. Davis is an 88 year old man with a complex medical history including:
	1. Spinal stenosis of the lumbar spine
	2. Peripheral neuropathy with weakness and sensory impairment
	3. Osteoarthritis of both shoulders
	4. Forestier's disease of the spine with bony fusion
	5. History of bladder cancer
	6. Laminectomy in 1962
	7. Spinal fusion in 1964
	8. History of non-healing lower extremity wounds

Mr. Davis has been using a power wheelchair for all of his mobility for the past five years due to severe peripheral neuropathy and spinal stenosis.  The neuropathy and stenosis have led to lower extremity weakness, and therefore Mr. Davis is unable to functionally ambulate even with a walker, and relies on his power wheelchair in order to manage his daily activities and remain living independently.  

Mr. Davis is unable to use a manual wheelchair due to severe osteoarthritis of both shoulders and diminished sensation of both hands.  Having a power wheelchair allows Mr. Davis to be mobile in his home environment without the assist of another person.  Without a power wheelchair, Mr. Davis would not be able to perform any daily activities, such as dressing, grooming, toileting, bathing, meal preparation, etc.  The following equipment is medically necessary to function and maintain living in his home:

Invacare Pronto Power Wheelchair with Midwheel Drive:
A power wheelchair is recommended to enable Mr. Davis to safely negotiate his home environment.  As stated previously, he is unable to propel a manual wheelchair due to severe arthritis and cannot ambulate to perform his daily activities due to the lower extremity weakness.  A midwheel drive base allows for closer negotiation of furniture in his cottage, as well as for the front wheels to swivel toward the rear when going forward.  In the past, Mr. Davis has incurred skin tears that have lead to long-standing open wounds from the non-swiveling front anti-tip wheels.  With the swiveling wheels of this wheelchair, Mr. Davis will be able to perform safe transfers without risk of injury.

Captain Seat with Semi-Recline:
This seat with the manual recline feature allows Mr. Davis low back support at an adjustable angle that can accommodate his lack of lumbar extension and hip flexion.

Hinged Foot Plate:
This footrest will provide support to the feet during mobility, but will hinge out the way to allow for safe transfers.

Flat-Free Drive Wheels:
The flat-free inserts will prevent rupture or puncture of the tire.  They will provide a maintenance free tire that does not require frequent pressure adjustments.

Retractable Joystick Control:
Mr. Davis must put much pressure on both armrests for his transfers, and having a retractable joystick allows him to use the armrests for this purpose without risk of inadvertently hitting the controls.  This feature also allows Mr. Davis to pull up to a table for meals and for deskwork.

Seat Elevator:
This feature will allow Mr. Davis more independence with his transfers as well as minimize the pain and wear on his painfully arthritic shoulders.

U1 Batteries:
This feature provides a power source to the power wheelchair.

Please do not hesitate to contact me if you require further information.  The above wheelchair equipment is medically necessary to allow Mr. Davis the ability to function independently in his home.

Sincerely,

_______________________				________________________
Laura N. Terry, MPT					M. Andrew Greganti, MD
(919)918-3224						(919)966-3063