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Letter of Medical necessityName: xxxDate of Birth: xxxIns Provider #: xxxDiagnosis: Name primary disabling condition (ICD code), name any additional relevant diagnosis affecting patientPhysician: Dr. Jane DoeClinic Name1212 High LaneCity, WA XXXXXP: XXX XXX-XXXXDear Madam or Sir:I am writing to request medically necessary Durable Medical Equipment for (John Doe). The request is for an Obi powered dining device, and 2 Microlight mechanical switches for independent operation, and a Mount N Mover dual arm wheelchair mounting system with tray, post, and wheelchair attachment hardware. This equipment will allow (John) maximum capability for self-initiated functional eating. I am a board certified occupational therapist in the state of WA specializing in neurodevelopmental therapy and have been treating (John) for 2 years.(John) is a twenty-year-old young man with quadriplegia cerebral palsy (CP). His cerebral palsy is characterized by involvement of all four limbs, as well as hypertonia throughout his body affecting the fluidity of movement. Often, he has involuntary movements and is strongly affected by uncontrollable primitive reflex movements. His spastic cerebral palsy also affects his mouth and pharynx, which impact his speech, eating, breathing, and ability to swallow. The stress of the spasticity has affected his postural alignment; he has scoliosis, windswept hips, along with upper and lower limb contractures. (John) is currently a level V on the gross motor function classification system (GMFCS). He is cognitively and verbally able to participate in own decision making process. Because (John) is unable to feed himself in a conventional way, he is permanently in need of an adapted method. He has participated in therapy for many years with an emphasis on goals to increase his ability for independent self-feeding. Many methods have been trialed with little to no long-term success due to the complexity of his disabling condition. Recently,(John) participated in a trial with an Obi powered feeding device, which was very successful. He was able to independently operate the device using 2 switches and feed himself an entire meal for the first time in his life. In addition, the Obi allowed him to access foods of all textures and consistencies, which has never been an option with past methods.Functional Limits: (John’s) quadriplegia CP prohibits him from performing activities of daily living (ADLs). He is dependent on caregivers and durable medical equipment (DME) for all ADLs. He is non-ambulatory and requires the use of an attendant propelled wheelchair for mobility. He has dysarthria, but is able to communicate most of his needs verbally. He intakes all food and nutrition orally, but is dependent on DME or a caregiver for preparation and physical feeding.Current Dining Practices: (John) is totally dependent upon caregivers to feed him each and every meal due to his inability to use his upper extremities to hold or lift a utensil, or be successful with any myriad of other methods trialed to date. Therefore, he currently has no way of independently providing any nourishment to himself. A powered feeding device is the only approach that has been effective and able to provide (John) access to independent eating at mealtimes, which makes this device medically necessary to allow him to maximize his capability for self-initiated functional eating. By gaining the ability to functionally feed himself through the Obi trial, (John) has changed his perception of eating from an arduous, loathsome, and often embarrassing task, to a more normal, enjoyable social experience that all non-disabled people enjoy. Therefore, it is expected that his net health outcome for the foreseeable future will improve, along with his overall quality of life.Additional health benefits will result by (John) feeding himself. The risk of aspiration and the ensuing possibility of aspiration pneumonia will be reduced when (John) is able to control when food is placed in his mouth with more fluidity of movement. Being fed by another person has been clinically shown to increase the likelihood of aspiration. Additionally, when self-feeding, most individuals eat more slowly than when they are fed by another person. The result of slower eating is a reduction in the risk of developing gastroesophageal reflux disease (as well as making meals and snacks more enjoyable). Therefore, (John’s) long-term health outcomes will be significantly improved by feeding himself. For all of the above reasons, I highly recommend that an Obi powered dining device be provided for him.The Requested Dining Equipment: The Obi powered dining device is a rechargeable battery operated medical device that allows people to feed themselves without using their arms or hands. Food is placed into 4 bowls that come with the device. The magnetically attached spoon rotates between the bowls by user operated switch controls, until the desired food is located under the spoon. The spoon then dips into the bowl, scoops up the food, and presents a rounded spoonful of food to the customized preset position near the user’s mouth. Once delivered, the user leans slightly forward to remove the food from the spoon.To accomplish independent eating, (John) will use the Obi powered feeding device positioned on top of a tray held by a Mount N Mover wheelchair mounting system. A Microlight mechanical switch located near his left ear will be used to move the spoon to the bowl of choice. He will then use a second Microlight mechanical switch positioned by his left leg, tapping it to activate the spoon to initiate food retrieval. This set up will enable (John) to feed himself, allowing control over when food is delivered to him. Also, for the first time, he will not be limited to certain food types that are germane to the technology being used. This device is capable of delivering all types of foods, including solid, chunky, sticky, thick, or soupy, so there will no longer be any caloric limitations due to food characteristics.Equipment Evaluation: (John) has been trialing the Obi powered feeding device on a daily basis for over a month. After initial set-up by caregivers, (John) is able to use the switches to operate the device to independently feed himself. There is no need for constant supervision or adjustment by caregivers. They are able to walk away and allow him privacy to feed himself. If (John) wishes to eat with others he is no longer exhausted by the experience of feeding himself or embarrassed by the amount of spillage, and therefore can socially interact with others in the home or out in the community if desired.The device is lightweight and portable with a rechargeable battery to allow it to be used in any setting. The food delivery pace is completely controlled by the user. It has a “training” mode, which remembers the spoon position that is set at the beginning of each meal, allowing ease and flexibility to maximize food retrieval success. The components are top rack dishwasher safe to allow for easy cleanup and hygiene.Based on the recent evaluation, these items have been found to be medically necessary for (John) and are not for his convenience. If you have any questions, please contact me at 555-123-4567. Signed: _______________________________ Therapist name, OTR/L, C/NDTOccupational Therapist9/13/2016 ................
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