|Standard Forms Reports And LMN > Standard LMN|
The LMN template is given below. The <> symbol in the template is filled with the data described inside the <> symbol.
LETTER OF MEDICAL JUSTIFICATION
<Patient Name and Address>
Primary Insurance: <prim insurance name> Policy Number: <prim policy number>
Secondary Insurance: <sec insurance name> Policy Number: <sec policy number>
DOB: <patient date of birth>
Patient Height: <patient height>
Patient Weight: <patient weight>
To Whom it May Concern:
<patient name> is a <age> year old <gender> with a diagnosis of <prim ICD9 description>, and <sec ICD9 description>, and <tertiary ICD9 description>, and <quadrary ICD9 description>, Additionally the patient presents with < 'Wheelchair Seating Eval' pull downs added to: cardio, bladder, vision, auditory, cognitive abilities, skin condition, sensation, upper extremity muscle strength, lower extremity muscle strength, trunk muscle strength, right upper extremity range of motion, right lower extremity range of motion, left upper extremity range of motion, left lower extremity range of motion, right upper extremity muscle tone, right lower extremity muscle tone, left upper extremity muscle tone, left lower extremity muscle tone, scoliosis, kyphosis, pelvic obliquity, posterior pelvic tilt, ambulation, head control.>
<'Wheelchair Seating Eval' used for the following>
<If Power Chair checked: Additionally, due to a severe weakness of the upper extremities this patient requires a power wheelchair to meet all of <his or her> independent mobility requirements.>
<If 'Patient Has Existing Wheelchair' checked: At the present time, <Mr. or Mrs.> owns a <Existing Wheelchair Age> old <Make> <Model> wheelchair. <If Reason Equipment Is Not Appropriate is filled: This chair is no longer medically appropriate for the following reasons: <Reason Equipment Is Not Appropriate>.> <If 'Patient Has Existing Wheelchair' not checked: The client does not own a wheelchair of any type.> For these reasons I am writing to recommend the purchase of a new wheelchair at this time. <Mr. or Mrs.> lives in a wheelchair accessible home. <If Transfers pull down selected: <He or She> <Transfers> in <his or her> transfers.> <If ADL's pull down selected: <He or She> <ADL's> in <his or her> activities of daily living.> <If Transportation field entered: <He or She> uses a <transportation> for transportation.> <If How many hours per day field entered: <He or She> spends <How many hours per day field entered> hours per day in a wheelchair.>
The provision of this wheelchair for <Mr. or Mrs.> <patient name> is consistent for patients with <his or her> medical condition and is in the standards of good medical practice. It is not for <his or her> convenience.
<If Ultralight Chair checked: <Mr. or Mrs.> <patient name> requires this wheelchair for the effective medical maintenance of <his or her> physical status and to promote maximum independence and safety during self care activities. <Mr. or Mrs.> <patient name>'s upper extremity strength and endurance are not sufficient to enable <his or her> to propel a standard manual wheelchair, lightweight, or high strength lightweight wheelchair. An ultralight wheelchair is recommended to enhance <Mr. or Mrs.> <patient name>'s overall function and maneuverability, and to maintain <his or her> strength and endurance. All of <his or her> activity outside of bed is in a wheelchair. HeShe puts a tremendous amount of strain and wear on the chair. All wheelchairs other than an ultralight are not designed to stand up to this level of activity. Additionally, the ultralight wheelchair is equipped with an adjustable rear axle position. This is required in <Mr. or Mrs.> <patient name>'s case since a posterior position of the axle increases stability for transfers. <Mr. or Mrs.> <patient name> has difficulty transferring safely without this option. Additionally, a posterior axle position improves the efficiency of independent propulsion. <Mr. or Mrs.> <patient name> is a very active individual. Although the wheelchair will be used primarily in the home, <he or she> will utilize the wheelchair to attend various other activities. These activities include <Patient Activities> .>
<If Needs Tilt In Space checked: Additionally, due to the severity of the patient's condition, <Mr. or Mrs.> <patient name> now requires a tilt-in-space frame. A tilt-in-space frame is required to assist in trunk positioning by shifting the patients weight through gravity, while maintaining the seat to back angle. The tilted position will help keep <his or her> hips back in the seating system, and will prohibit <him or her> from sacral sitting. Additionally, the tilted position provides ischial and sacral pressure relief reducing the likelihood of decubitus ulcers in the future. <Mr. or Mrs.> <patient name> is unable to sit upright in a standard frame wheelchair. Continued seating in <his or her> present mobility system will result in further deterioration of <his or her> condition. <His or Her> current mobility system cannot be modified to meet <his or her> medical needs. This wheelchair will accommodate <his or her> physical deformities, as well as relieve pressure on the back and sacrum.>
<If Power Chair checked: <Mr. or Mrs.> <patient name> is unable to propel a manual wheelchair due to upper extremity weakness and the overall deterioration of <his or her> physical state. The power wheelchair should be furnished with programmable controls to enable the power wheelchair to be programmed to <Mr. or Mrs.> <patient name>'s specific environment and medical needs. The parameters to be adjusted include forward, turning, and reverse speeds, acceleration and deceleration, and braking speed. With this feature <he or she> will be capable of safely operating the controls of the power wheelchair. The provision of this wheelchair will enable <Mr. or Mrs.> <patient name> to negotiate <his or her> home environment, and can reduce the stress placed on <his or her> physical state. The alternative to the provision of this power wheelchair would be bed confinement.>
<If Custom Back checked: Mr.Mrs. has a significant spinal deformity and a severe weakness of the trunk muscles. Additionally, <he or she> has a need for prolonged sitting tolerance and postural support to permit functional activities, and pressure reduction cannot be met adequately by a prefabricated seating system. <He or She> has been evaluated in a number of positioning devices, and a custom made seating and positioning insert is determined to be the most appropriate means of providing proper spinal alignment and support. This device is specifically made for <Mr. or Mrs.> <patient name> from <his or her> measurements. <He or She> cannot be properly positioned with a pre-fabricated or planar seating system. This unit will be incorporated into <his or her> wheelchair base.>
<Line Item Number> <Description>
<Justification Number> <Justification> Note: May have several justifications per line item.
Please phone my office with any questions regarding this patient.
<Physician's name>______________________________ Date:____________________
UPIN: <Physicians's UPIN #>
Doctor's Address: <Physician's Address>
Doctor's Phone:<Physician's Phone>
<Therapist Name>________________________________ Date:____________________