Cerebral Palsy and Letters of Medical Necessity.

Letters of Medical Necessity

As discussed previously in the “Financing Care” section, having a family member with cerebral palsy can mean that your family will have a lot of medical expenses. Funding for other items your child may need such as, communication aids, seats, toilet aids, standers, adaptive feeding devices, and braces, may be at available to you through your insurance company or through a private philanthropic organization.
The funding agencies that would be in charge of compensation for such medical items, such as your insurance company or a private philanthropic organization, almost always demand a letter of medical necessity from a therapist (physical, occupational, or otherwise) or from a physician to prove your claim that your child’s medical equipment was necessary to his successful treatment. The claim or appeal will be likely be refused if you do not include a letter of medical necessity which includes a detailed explanation of the condition or disability that makes the equiment a necessity for your child.

It is possible that your particular physician may not fully be acquainted with the rules of your insurance company which will affect whether or not you are reimbursed for your child’s medical equipment. (Each insurance company or state may have slightly different rules.) To be on the safe side, educate yourself on the rules so that you can be a better advocate for your family. You should become familiar with the bare minimum of information that needs to be included in a letter of medical necessity. Otherwise, the letter may contain insufficient information, which may lead to the funding agency denying your claim.

The following is an example of a thorough and professional letter of medical necessity taken from Dr. Freeman Miller’s Cerebral Palsy: A Complete Guide for Caregiving. If you prefer, you can take a copy of this letter to the physician who is writing your child’s letter of medical necessity, and ask that he or she adhere to the example letter below.

    “ To Whom It May Concern (or, better, to a specific employee of the funding agency): 

    John Smith is a 5-year-old male with a primary diagnoses of cerebral palsy. He was seen at the Seating Clinic at the Alfred I. DuPont Institute in Wilmington, Delaware, on June 23, 1993, for the prescription of a new seating system to meet his positioning needs. 

    John presents with the following: generally decreased tone in upper and lower extremities, and fair head and trunk control. He is dependent in transfers and mobility. He is cognitively severely delayed. He is incontinent in bowel/bladder. He has frequent respiratory complications and is subject to bronchitis and pneumonia, and he receives chest therapy. He occasionally aspirates, he has increased skin sensitivity, and he has seizures, but they’re generally under control with his medication. He must have a tilt-in-space wheelchair with appropriate positioning to provide safety and support, and to facilitate breathing and feeding.

    His current seating system is a Zippie tilt-in-space that is three years old. It no longer meets his positioning needs because he has outgrown it, and the seating insert needs to be changed to meet his current positioning needs.

    The goals for John for seating are to maintain posture, protect skin, provide comfort, and enhance function. Upon evaluation, the Seating Team has recommended that the following equipment be prescribed for John:

    Action Tiger, desk arms, swing away detachable elevating leg rests, semi-reclining back, special seat depth, stroller handles, custom positioners and lateral hip guides, high brackets, solid seat with attaching hardware, solid back with attaching hardware, shoe holders, heavy-duty straps.

    The Action Tiger is prescribed because it is a manual wheelchair for total positioning, and because he is dependent in mobility. The tilt is needed because he is hypotonic in head and trunk. He also has difficulty breathing, and it will help aid in feeding. It will help with low endurance and pressure relief, and it will control seizure reaction. The adjustable height arms are needed to support tray at right height, for upper body support and balance, and for ease of transfers. The I-back will bring side supports close to trunk, but insert will fit the full width of the wheelchair. The laterals will encourage midline trunk position, compensate for lack of trunk control, provide safety, and contour around trunk for better control. The chest harness is needed for safety in transport by providing anterior support, preventing forward flexion, and retracting shoulders. The headrest is needed for poor head control due to low tone, active flexion of head, posterior lateral support, safety in transfers, and to facilitate breathing. The clear tray is needed for functional surface for schoolwork, stimulation, upper arm and trunk support, inability to access tables, computer, and a base for augmentative communication devices. The shoe holders are needed to control increased extension or spasms in lower extremities, excessive internal rotation, and to prevent aggressive behavior for safety. The anti-tippers are needed for safety.

Should you have any questions regarding these recommendations, please do not hesitate to call me at (302) 555-5850. We hope that you will be able to accommodate these needs in an expedient manner. Thank you for your cooperation and assistance in this manner.

Sincerely,

Freeman Miller, M.D.

Pediatric Orthopedic Surgeon”

Be sure to take note of when it was your child’s letter was sent to the funding agency, and if three or four weeks pass without word from them, you might want to call the agency to inquire about the status of your claim. Always keep a record of when you call and with whom you speak to, and always try to remain calm and collected when dealing with the insurance company. If, however, you are unable to obtain a straightforward response as to when your claim will be processed, do not hesitate to enlist the help of your physician.

Please feel free to

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Cerebral Palsy and Jobs, Estate Planning, Health Insurance,
Letters of Medical Necessity, IDEA, DDA & Bill of Rights Act,
Americans with Disabilites Act, Rehabilitation Act of 1973, and Vocational Rehab.