Healthcare Professional
How to Refer a Patient to Alternate Medical Supply:
- Call (631) 585-5000 or (800) 244-0526.
- Our patient service coordinators will take the order in an efficient and expedient manner.
- AMS will coordinate with physicians, social workers, nurses, and therapists to assess the home care needs of the patient and to provide continuity of care.
- AMS will simplify and streamline the order taking process by performing insurance verification and coverage (if applicable) for the prescribed equipment and/ or supplies and by getting the necessary paperwork signed by the treating physician.
- Equipment and supplies will be delivered to the patient's home.
- Our therapists and/or equipment technician will instruct the patient and caregivers on the safe and appropriate use of the equipment provided.
- Patient progress is reported to the physician and referral source.
A Certificate of Medical Necessity (CMN) must be completed and signed by the physician before certain items can be dispensed to Medicare beneficiaries. Click on the link below to find which items require a Certificate of Medical Necessity under the Medicare Program.
Letters of Justification
Insurance companies often require a letter of medical justification, in addition to a doctor's prescription, to substantiate the medical need for equipment and/or supplies. This letter can be written by any healthcare professional that works directly with the patient and is aware of their needs. The treating physician often co-signs the letter of justification. However, this is not always necessary. Below is some helpful information to keep in mind when writing a letter of justification, as well as some sample letters that successfully received funding.
**IMPORTANT INFORMATION**
If you are a physician or therapist writing a letter of justification for a for a wheeled mobility item (wheelchair, stroller, scooter, etc.) for a New York Medicaid beneficiary, please read the following Medicaid guidelines. All of this information must be included in your letter of medical necessity or Medicaid will return the Prior Authorization request stating that there is not enough documentation provided.
WHEELED MOBILITY EQUIPMENT GENERAL GUIDELINES
Wheeled mobility equipment is covered if the recipient's medical condition is such that without the use of the equipment, the recipient would otherwise be confined to bed, chair, or home and the recipient is not ambulatory or not functionally ambulatory. A prior approval request must, at the least, include the following documentation of medical necessity:
1. A list of all current wheeled mobility equipment (e.g., make, model, serial number, age) and explain why it no longer meets the recipient's medical needs (e.g., give cost estimates of repair of equipment).
2. A description of the equipment and accessories as ordered (e.g., make, model, size, seat and back dimensions) and provide relevant recipient measurements (e.g., height, weight, chest, shoulders, thighs, legs).
3. A narration of medical necessity for the wheeled mobility equipment and related accessories and an estimate of how long the equipment will be needed (e.g., degree of ambulation in customary environment, medical conditions, intended use, amount of time daily the equipment is used).
4. A statement of the alternatives considered or attempted (e.g., manual versus power, off the shelf versus custom accessories) and why these alternatives do not meet the medical need.
5. A description of the customary environment and caregiver supports (e.g., skilled nursing facility, OMRDD-certified residence, private home, home health or waiver services); give details of the results of trial of equipment in this environment (e.g., fitting through doorways, access to home, transportable, ability to safely operate).
Justification Letter Outline
A. Use official letterhead with an appropriate salutation
B. First Paragraph
Introduce your patient and explain the diagnosis that they have which is relevant to the equipment you are ordering. (For example, if you were ordering an adaptive stroller because the child has poor head control secondary to cerebral palsy, you wouldn't say their primary diagnosis is diabetes with cellulites of the foot. Although the child may have all of the above diagnoses, you should emphasize CP with poor head control because it most relevant to ordering the stroller.)
Explain the functional limitations of the patient and the prognosis. Mention that they attend physical/occupational therapy, if applicable.
C. Middle Paragraph
Name of assistive technology/equipment that you are recommending and how this will improve the patient's situation. Individual descriptions for each component of assistive technology being requested with justification statements as it pertains to the individual are also helpful. Emphasize terminology that is consistent with the funding agency from which financial assistance is being sought. Provide a statement describing some possible consequences for patient if the equipment is not funded and emphasize function and safety. Describe the patient's environment. Has the patient been able to use a demo of the product with positive results? If so, give details of the patient using trial equipment in the home. Does this equipment have the capacity to grow with the patient? (Insurance companies love to see that the patient demonstrated that the equipment suits their needs and that it can be grown if a child grows or if an adult gains weight.) If applicable, emphasize that the patient would be able to be more active both inside their home and in their community if they had the equipment.
**Also, it is helpful to mention the current equipment that this patient has and why it is no longer suitable or why it no longer meets medical the needs of the patient.
Most important: Do not fall prey to recommending an item because it will improve the quality of life of the caregiver. For example, if you are trying to receive funding for a mechanical bath lift, do not explain how the caregiver has back problems and is unable to lift her disabled child into the tub. Instead, emphasize how the safety of the child is compromised because the caregiver is unable to provide adequate support when lifting the child into the tub.
D. Last paragraph
Thank the agency for their consideration and assistance in funding. Provide a name and phone number to contact if the agency has any questions.
E. Closing
Sincerely,
Signature
Complete name and all credentials, unabbreviated versions, of the practitioner requesting the funding. Also, list the name of agency from which you are a referral source, if applicable.
Useful terms:
Prevention of/minimize the effects of
Example: John Doe spends up to 8 hours per day in his motorized wheelchair. I am recommending a gel cushion to prevent the formation of pressure ulcers and to help maintain skin integrity.
Promote or Support
Example: An activity tray on John Doe's wheelchair will promote therapeutic activities.
Emphasize safety
Example: John Doe requires bumper guards on the side rails of his hospital bed to reduce the risk of injury during seizure episodes.
Remember, no product is ever "perfect" and they aren't meant to last forever because the functional status of the patient and their particular situation are always apt to change.
A physician's note to endorse the report is helpful.
Always use "patient" not "client." The equipment is being funded because the patient requires it for medical reasons, not because it will make their life, or the life of their caregiver more convenient. Physicians do not have clients.
Always define the product as a medical necessity and justify it accordingly. It is very specialized to the individual.
Establishing the long-term benefits of using the recommended equipment is also advantageous, such as:
- Improved bone growth and density as a result of weight bearing activity
- Strengthening of anti-gravity muscles/minimizes contractures
- Development of hand/eye coordination
- Opportunity for cognitive growth
- Improved respiratory activity as a result of proper seating and positioning
- Development of head & trunk control as a result of proper alignment and support
- Increased independence
- Improved self-esteem
Sample Letters
To Whom It May Concern:
Name of patient is a seven year old boy with a diagnosis of downs syndrome, agenesis of the corpus collosum, and developmental delay. He requires assistance with sitting secondary to poor voluntary control over his head, trunk, and arms secondary to decreased muscle tone and spasticity with right hemiparesis.
I am recommending the Special Tomato Multi-Positioning Seat with the Mobile Floor Base, Push Chair Base, and Activity Tray to provide proper sitting positioning and support for Name of patient. The Special Tomato has three soft, flexible cushions that give lateral support to the head, trunk, and legs. In addition, these cushions are impervious to fluids, which makes clean up easy and further extends the life of The Special Tomato. The Seat Cushion has Hip Flex, which is a feature that allows for positioning of Name of patient pelvis at the exact angle needed. His hips can be adjusted between 15 degree of hip flexion and 15 degree of hip extension. As Name of patient abilities improve and change, this seating system can accommodate those changes and provide the best support for him.
The Mobile Floor Base is medically necessary because it will allow Name of patient to be safely transferred from room to room at his home or school without compromising his positioning. It also allows for 25 degree of tilt-in-space to place Name of patient at the correct angle for a variety of activities.
The Push Chair Base is medically necessary because Name of patient requires a stroller base that will allow him to be transported to school, therapy sessions, doctor appointments, and other social activities. He and his family live on the third floor of an apartment building and his caretakers are unable to transport him down the stairs in a wheelchair. This stroller base has successfully passed the ANSI/RESNA WC/19 regulations for transportation using a 5-point tie-down system.
The tray is medically necessary because it will provide a stable base for Name of patient to bear weight to develop strength and control in his shoulder and arms. This tray will also provide a surface for a variety of activities for Name of patient (ie. tactile activities, visual activities, mealtimes, etc.).
As Name of patient grows, his positioning needs will change as well. The Special Tomato provides up to six years of growth along with the capability to accommodate his changing positioning needs. The Special Tomato with Mobile Floor Base and Push Chair Base will provide proper positioning and support for Name of patient to continue to learn and develop to his fullest potential. Thank you for taking the time to consider this equipment for Name of patient. If there are any further questions, please call my office at the number listed above.
________________________________________________________________________
(Signature) (Date)
To Whom It May Concern:
Name of patient is a 5 and a half year old child diagnosed with lissencephaly, cerebral palsy, seizure disorder, developmental delay, and hypotonia. Due to her multiple problems and inability to ambulate, a Libre Folding Tilt Wheelchair is being prescribed for Name of patient. Because she cannot sit or stand without assistance, she needs to be tilted back so that she can be properly supported. She also needs to be tilted back during seizure episodes. The tilt rotational frame will keep her in the desired 90/90 position while she is titled back and gravity will prevent her from thrusting herself out of the chair. In addition, the 90/90 position will help to prevent her from developing extension contractures. Adjustable height arms are recommended for the chair to give her arms support and to correctly align them on the chair. Also, flat free foam inserts are recommended for the pneumatic tires so that the family does not have to be concerned with continually filling the tires with air.
A custom solid seat and a custom solid curved back have been ordered on adjustable drop hooks so that Name of patient can be kept in a proper seating posture, along with being properly aligned in the wheelchair. Both the seat and the back will have Sunmate foam to protect her from developing pressure sores. A three-piece headrest is necessary to keep her head properly supported and protected, especially during transportation. Name of patient will be using this wheelchair on the school bus, so a transportation option needs to be added to the chair.
Because she has a tendency to slide to the side of a chair, hip guides built up on the sides will help stabilize her pelvic area. Swing away lateral trunk supports have also been ordered to stabilize and properly align her trunk. Shoe holders are necessary to keep her feet and legs properly aligned on the chair. Plus, they will keep her feet from kicking out during seizure activity. A padded seat belt is also recommended to keep her secure in the chair and to prevent her from thrusting herself out of the chair. A dynamic butterfly harness will be needed for the same reason, especially during transportation. A wheelchair tray is necessary to give Name of patient proper shoulder and hand alignment. The tray will also be useful for caregivers to use during feeding and other therapeutic activities.
A Libre folding tilt wheelchair is medically necessary for Name of patient and because growth is incorporated into the chair, it is expected that she will be able to use this chair for approximately three to five years. Thank you for your consideration.
________________________________________________________________________
(Signature) (Date)
To Whom It May Concern:
Name of patient is a 50-year-old male, who is 6 feet 2 inches tall with a weight of 240 lbs. He is diagnosed with COPD, Type II diabetes, h/o CVA, and presents with multiple medical complications, including left hip vascular necrosis and bilateral lower extremity cellulites. Name of patient is impaired in ambulation and wheelchair dependent for functional mobility.
Current Status:
Name of patient has poor muscle strength of all four extremities.
Range of Motion
Hip | -10 to -90 degrees with left hip abduction and right pelvic obliquity |
Knee | 0 to -90 degrees |
Ankle | Bilateral plantar flexion deformity |
Recommendation:
- Motorized wheelchair 20Wx20D with full length adjustable height arms, swing away elevating leg rests with adjustable angle foot plates.
- 20" back height
- Seat belt
- Infinity max contour cushion with Flo-Gel insert
- Adjustable pelvic obliquity wedge
The above recommended wheelchair will facilitate independent mobility in his home and community, improve his sitting posture, relieve pain, increase sitting tolerance, improve his functional level, and meet transportation goals.
Due to his poor physical status and his current inadequate wheelchair, he is presently unable to fully participate in ADL, social, and vocational activities. Please give this request your earliest attention.
Sincerely,
Signature
