The Perlman Center’s physical therapy coordinator, Melissa K. Tally (at left), educates the parent of a young patient about the functional and developmental importance of early standing.
by Melissa K. Tally, PT, MPT, ATP, and Erin M. Pope, PT, MPT, ATP
Standers are a common piece of adaptive equipment recommended for individuals with motor impairments and physical disabilities.1 While there is strong evidence to support the use of adapted standing devices across the lifespan for persons affected by physical disabilities, obtaining funding approval for the equipment isn’t always easy. The documentation written by the clinician is the key to success in securing funding for standing devices, which makes it essential to ask the question: “Is my documentation bulletproof?”
In our experience, there are key do’s and don’ts that aid in creating an effective letter of medical necessity (LMN). A vitally important factor often overlooked is ensuring that LMNs connect each desired accessory to the patient, and that medical justification for each is articulated. If this information is not included in the initial submission, a stander may not be denied but it may be underfunded. This can leave the supplier to absorb the cost of options that may not be funded in order to provide the equipment.
Plan Well, End Well
As with any LMN, the process begins with the evaluation. This is very important to determine the personal choice and clinical recommendation for an optimal standing device and options for the patient. The clinician’s assessment findings drive the justification for each option. A clinical picture of the patient must be created along with medical need, functional outcome, and consequences that may occur without it. Per the Rehabilitation Engineering & Assistive Technology Society of North America (RESNA),2,3 the evaluation includes the physical assessment, clinical assessment, and equipment trials.
Our center has developed a detailed process for all adaptive equipment evaluations. The physical assessment includes information about the environment in which the equipment is to be used and a thorough medical history and systems review. We include communication, cognition, bowel/bladder, hearing, vision, cardio-respiratory status, skin integrity, current functional level with activities of daily living (ADLs), and 24-hour positioning needs. This paints a clear picture of the complex need for adaptive equipment and is helpful for future recommendations, as our patients often have multiple equipment needs. The clinical assessment includes posture assessment, strength, range of motion, tone presentation, upper- and lower-extremity function, transfers, and ADLs.
Together, these findings guide clinicians to the equipment trial. Some types of standing frames may be weeded out based on the above findings, but therapists should never make recommendations without a trial. There are key differences in standing frame types and styles that can make a significant difference, not only in positioning of the patient but in the overall compliance with a standing protocol. When completing the trials, document patient tolerance to equipment, ability for safe transfers, positioning/control of contractures, and tonal patterns inhibited/elicited. These notes can help justify recommendations and explain why some standing frames have been ruled out. If the patient is initiating a new standing program, more than one trial may be needed.
Standing Systems by Type
There are four key types of standing systems: single-position standers (prone or supine), multipositional standers (used in either configuration and often present more adjustable accessories), sit to stand standers (transferred into equipment in a sitting position then transition to standing), and dynamic standers (allow some self-initiated mobility in standing). The common accessories available to therapists to create a standing solution can include the following: the standard base or standing frame, headrest, trunk lateral supports, chest straps, pelvic straps, hip lateral supports, knee pads, footplates, sandals, foot straps, and tray. Most of these accessories are common external supports used with adaptive equipment and could greatly impact the functional outcome of the standing protocol. If accessories are not appropriately justified in the LMN, it may result in the equipment being underfunded.
At times, the type of standing frame you determine to be most appropriate may be more difficult to fund. Payors may find a multitude of reasons to deny or limit funding for specific standing features. For example, sit to stand standers can be seen by funders as two types of equipment—a stander and a chair—which can make it difficult to get approved. If this standing frame is recommended, it is important to justify the reason for the sit to stand feature, such as to allow for safer transfers in/out of the stander or to gradually improve range of motion for standing.
Dynamic standers can also be equipment for which it is difficult to attain funding authorization. Funders may suggest that a stander does not offer mobility but standing, and a wheelchair should be considered for mobility. In this case, it is important to justify the reasons other standing frames are not appropriate, and how the mobility of the dynamic stander is medically necessary. One reason for a younger child may be that the equipment allows them to be at an age-appropriate level with their peers. It may also offer a means for upper-extremity strengthening and access to ADLs and learning. For an older patient, this type of stander may allow increased access and independence to complete mobility-related ADLs or assist with independence and access at a job.
The multipositional stander may be questioned as too complex, and the funder may ask that a single-position stander be considered. The therapist therefore must be prepared to justify reasons why this patient’s physical impairment requires the multipositional stander. Typically, when recommending this stander type, the functions of a single-position stander (supine or prone) are not appropriate for the patient’s level of need. The additional features and adjustability of the accessories on the multipositional stander will allow for improved postural alignment, optimally address and accommodate asymmetries, and provide changes with growth.
Standing frames may be more readily funded for young children than adults. Some funding companies do not necessarily see the medical necessity of standing after the age of 14 years. Standing is an integral part of the developmental sequence and is one of the building blocks that leads to exploratory mobility.4 A child who is unable to stand may be missing out on developmental learning and interaction with the environment. We know the many benefits of standing as well: improved range of motion through the lower extremities, increased bone density and hip stability, and a reduction in spasticity.1 These benefits, important for the younger child, are no less important for the adult.
The justification of how these benefits come into play for the older patient is very important. We recommend standing frames across the lifespan for our patients, and the denial rate we see is no larger for one group than another. We perform comprehensive evaluations for all ages with thorough trials of the equipment options available and needed for the patient. If a stander continues to be denied after repeated appeals or is a noncovered item for the insurance funder, we help connect the patient and families to alternative funding sources and community resources to ensure they have access to standing.
| RECOMMENDATIONS | JUSTIFICATION |
| Standing Frame | This was found to be the most appropriate stander choice for patient. It is appropriate for current size and offers adequate growth for patient to be able to use the standing device for the next several years. |
| Headrest | Necessary component to provide appropriate head support. Patient is unable to hold head upright and requires head support in the stander. |
| Lateral supports, covers and hardwareChest Strap |
Necessary to provide external support to the trunk, limiting spinal curvature and promoting upright spinal alignment. Patient is unable to maintain trunk in an upright, midline position. The lateral pads provide that support in the stander. |
| Hip supports, covers and hardwarePelvic Strap |
Necessary to maintain neutral lower extremity alignment. Patient is unable to maintain hips and pelvis in a midline position. These pads provide the necessary support to keep legs in standing position. |
| Knee Assemble with Pads |
Necessary to maintain neutral lower extremity alignment. Patient is unable to maintain knees in an extended position. These pads provide the necessary support to keep legs in standing position. |
| Foot Sandals | Necessary to provide support and alignment to the feet and maintain neutral positioning within standing device. This prevents patient’s feet from sliding off footplate or moving out of position in the stander. |
| Footplate | Necessary to adjust footplates for optimal contact and support to the lower extremities. Patient is unable to maintain feet in a plantigrade position. The footplate is adjustable to accommodate for this need. |
| Tray | Necessary to provide upper extremity support and provide a surface for fine motor skill development. Patient is unable to maintain an upright position. The tray provides a surface to allow the upper extremities to assist with pushing up and keeping trunk upright. |
| Table A: Stander/Accessories Justification | |
| Goals Of Recommended Equipment: Stander |
| To provide a means for lower extremity weight bearing, upright standing, and upright mobility within the (home, school) environment to facilitate participation in age-appropriate play and activities of daily living. |
| To provide an option for upright positioning at (home, school) to assist with strengthening, pressure relief, pain, and improved range of motion. |
| To promote neutral postures and lessen development of secondary complications such as scoliosis, hip subluxation, and joint contractures. |
| To provide a means for carry-over of therapeutic exercise/standing protocol prescribed by patient’s physical therapy team and physicians. |
| To provide patient with a means for upright, lower extremity weight bearing to improve lower extremity range of motion and bone mineral density. |
| To provide patient with a means for lower extremity weight bearing and positioning to improve hip development and reduce further hip subluxation. |
| To provide external supports to allow neutral alignment of the spine, pelvis, and hips to lessen orthopedic complications from sustained sitting posture and abnormal muscle tone. |
| To provide an age-appropriate position in order to interact with peers and caregivers, to further enhance patient’s cognitive and social development. |
| To promote optimal bowel and bladder function. |
| Table B: Goal for Standing |
Patient Information Essentials
So the evaluation is complete and the optimal standing frame has been recommended. What needs to be included in the letter of medical necessity? Always include the patient’s name, date of birth, height, weight, and a summary of medical history; including primary diagnosis, onset, and secondary diagnoses. We also include the name of the referring physician, the credentialed supplier, and the evaluating therapist. Assistive Technology Practitioner (ATP) is a certification that all suppliers of adaptive medical equipment should have. Some evaluating therapists have this as well.
After providing some background about the patient, the referral, and the evaluation, therapists must document the presenting problem, current functional level, medical necessity for type of equipment recommended, and equipment that was trialed. Detail the equipment trialed and why the patient requires a specific type of stander over the others. Be specific in regard to positioning needs and why other standing frames are not able to accommodate the patient. Provide evidence that the patient is able to use the device safely; if not independently, describe that caregivers are able to assist with safe transfers and use of the device.
Furthermore, it is a good idea to include a description of the prescribed standing protocol and any expected outcomes or goals related to the use of a standing frame. Please refer to Table A for a justification list for a stander and recommended accessories. Table B shows a list of goals used at our center when a stander is recommended.
Specify, Connect, and Details for Success
In summary, make sure the letter remains patient specific. Individually justify each component for the patient: why a component is necessary for the equipment, what it does, how it supports the patient’s impairments (ie, head support is needed due to the patient’s muscle weakness and poor head control, hardware is required to attach head support to frame and allow it to function safely). Connect each component to the patient and a documented impairment. Make sure the justification for components matches the clinical summary (ie, if requesting a sit to stand stander due to knee contractures, be sure to include objective documentation of knee ROM). Use the evidence when applicable.
There are several articles and systematic reviews supporting the benefits of standing and a standing protocol.1,5 Detail objective measures of improvement expected with a standing program. Document subjective and objective benefits the patient received during a standing trial (pain relief, increased ROM, increased weight bearing, etc). It is important to discuss negative impacts if the standing equipment is not received. Is the patient at risk for contractures or asymmetries, or are they confined to static sitting for long periods? These negative effects can be linked back to the supporting research.
Two documentation templates developed at the Perlman Center at Cincinnati Children’s appear in the online version of this article (see below). The first template has a basic layout of the information discussed previously in this print article. The second template is more detailed and was designed to allow our clinicians to be more effective and to improve the paperwork process from the evaluation to documentation of the letter. This template continues to be a working document as we are constantly reviewing necessary edits and additions based on the questions we are being asked by the funding agencies to further justify medical necessity. RM
Melissa K. Tally, PT, MPT, ATP, and Erin M. Pope, PT, MPT, ATP, work for the Perlman Center at Cincinnati Children’s Hospital and Medical Center. The center is part of the Cincinnati Children’s Hospital CP program. For more information, contact [email protected].
References
- Paleg GS, Smith B, Glickman LB. Systematic review and evidence-based clinical recommendations for dosing of pediatric supported standing programs. Pediatric Physical Therapy. 2013;25(3):232-247.
- RESNA Code of Ethics. Retrieved from http://www.resna.org/sites/default/files/legacy/certification/RESNA_Code_of_Ethics.pdf
- RESNA Standards of Practice. Retrieved from http://www.resna.org/sites/default/files/legacy/certification/Standards_of_Practice_final_10_10_08.pdf.
- Bower E. (2009). Understanding movement, both typical and in the child with cerebral palsy. In: E. Bower (Ed). Finnie’s Handling of the Young Child with Cerebral Palsy at Home, 4th ed. London: Butterworth Heinemann Elsevier; 101-118.
- Glickman LB, Geigle PR, Paleg GS. A systematic review of supported standing programs. J Pediatr Rehabil Med. 2010;3(3):197-213.
| Simple LMN TemplatePatient name: Clinician:Patient DOB: Supplier:Referring MD: Funding Source:
Onset of Injury: Height/Weight: GENERAL INFORMATION Patient is a xx-year-old with diagnoses of (enter diagnoses). The disabilities present as a result of the diagnoses are (mild, moderate, severe, significant). Patient presents with (spasticity, abnormal tone, low tone, extensor tone, flexor tone) in (all of, upper, lower) extremities with (decreased, increased, abnormal) strength in the (trunk, neck upper extremities, lower extremities, all extremities). Patient requires adaptive equipment for all positioning and activities of daily living, and supported lower extremity weight bearing. Patient was seen this date by a member of the assistive technology team and ATP credentialed vendor for a comprehensive evaluation for a stander. PRESENTING PROBLEM: Stander Patient is dependent on adaptive equipment to maintain joint range of motion and prevent deformity, maintain good bowel and bladder function, interact age appropriately with peers and caregivers and perform functional activities of daily living. Without the assistance of adaptive equipment, patient is at risk for contractures and bony abnormalities and has no means of functioning in his environment. Patient is in need of a static standing device to promote lower extremity weight bearing. Patient tolerates (#) minutes of an established standing protocol prescribed by a physician. Patient currently has a (free text) stander that is xxx years old. Patient presents with (abnormal tone, spastic tone, flexor tone, extensor tone, dyskinetic tone, decreased strength, impaired motor control) throughout the (trunk, neck upper extremities, lower extremities, all extremities). Patient demonstrates (increased, decreased, limited, impaired) (active, passive, active assisted) range of motion in (bilateral, right, left) (upper, lower) extremities with (mild, moderate, severe) deficits in functionality. Patient is (unable to sit without maximal supports, unable to stand without maximal supports, does not tolerate standing or ambulating due to physical deficits sit without maximal external support) as a result of the diagnoses. Patient requires (full, contoured, custom) external support to maintain upright trunk and head control for functional activities. EQUIPMENT TRIALS Various standing systems were considered that would be appropriate for patient’s medical condition. The standing systems explored included free text. Patient’s needs cannot be managed by the free text as it is not able to free text. After exploring the various options, it was determined that these standing systems did not meet the needs of the patient and family with regards to functional upright positioning and lower extremity weight bearing. It was determined that patient would best benefit from the free text. The new standing system will accommodate the current postural abnormalities, impaired motor control and physical limitations while providing optimal support, adapted positioning, and lower extremity weight bearing. This standing system meets all of the patient’s needs, the family’s needs and is the most fiscally and financially responsible choice. This standing system will be used in the (home, within the school system) for dependent upright positioning and proper postural support for weight bearing and functional participation. Goals of Recommended Equipment: (see Table B above) SUMMARY Patient is dependent for all postural support and requires a standing device to compensate for multiple medical conditions. Patient presents with a (weak trunk, limited extremity function, impaired mobility, abnormal tone, limited ability to control body, decreased range of motion). Patient requires a means for functional positioning in the home. Please consider these recommendations for the standing device justified below. Thank you for your time, EQUIPMENT PRESCRIBED (See Table A above) If you have any questions or concerns, please contact me at (xxx) xxx-xxxx. Therapist Physician, M.D. License # License # Date: Date: |
| Complex LMN TemplatePatient name: Clinician:Patient DOB: Supplier:Referring MD: Funding Source:
Onset of Injury: Height/Weight: GENERAL INFORMATION Patient is a xx-year-old with diagnoses of (enter diagnoses). The disabilities present as a result of the diagnoses are (mild, moderate, severe, significant). Patient presents with (spasticity, abnormal tone, low tone, extensor tone, flexor tone) in (all of, upper, lower) extremities with (decreased, increased, abnormal) strength in the (trunk, neck upper extremities, lower extremities, all extremities). Patient requires adaptive equipment for all positioning and activities of daily living, and supported lower extremity weight bearing. Patient was seen this date by a member of the assistive technology team and ATP credentialed vendor for a comprehensive evaluation for a stander. HOME ENVIRONMENT AND TRANSPORTATION CONSIDERATIONS Patient lives at home with xxxxxxx. Home is a (single story, two story, apartment) with (#) stairs to enter (with, with no_ ramp access). The home has a(n) open living area. The bathroom is on (1st, 2nd) floor with (standard with tub/shower, walk in shower). The bedroom is on the (1st, 2nd) floor and is accessible. Patient is transported via (community transit, standard vehicle, adapted van). Patient requires (minimal, moderate, maximal) assistance for self-care needs and mobility. For transfers, (full caregiver assist, maximal assistance, moderate assist, minimal assist) is required.
CURRENT MEDICAL/PHYSICAL STATUS Cognitive Status: (impaired, no deficits noted, delayed) Skin Condition/Integrity: (WFL, history of skin breakdown, at great risk for skin breakdown secondary to limited ability for independent repositioning) Bowel/bladder: (independent, dependent, requires assist for transfers, total assist) Hearing/Vision: (WFL, impaired hearing, visual processing delays, wears glasses) Cardio-respiratory status: (WFL, disease related compromise, progression of medical complications related to respiratory status is expected, requires tilt and recline for improved respiration) Tone/Movement/Strength: (abnormal, normal, low, spastic, ataxic, dyskinetic, high) muscle tone throughout. (increased, decreased) functional movement due to (abnormal, normal, low, spastic, ataxic, dyskinetic, high) tone and (impaired, increased, decreased) strength. Orthopedic considerations: (unremarkable, hip subluxation/dislocation, scoliosis with XX degree of curvature, at great risk) due to his (abnormal, normal, low, spastic, ataxic, dyskinetic, high) tone with (increased, impaired, decreased) motor control Ambulation/Functional Walking Status: (non-ambulatory, non-functional ambulation, able to ambulate short distances within his home with xx assist, independent with assistive device) Bed confined: nights only, requires (minimal, moderate, maximal, full) assist for all daily living skills and requires (minimal, moderate, maximal, full) caregiver assist for all medical management Chair confined: (#) hours/day.
Measurements Most recent height : Most recent Weight:
CLINICAL ASSESSMENT Sitting Posture/Balance: Sitting balance is (poor, fair, good). Patient is unable to remain in an upright, midline posture for extended periods without (minimal, moderate, maximal) external supports. Righting/Equilibrium reactions are (present, delayed, absent). Protective Extension reactions are (present, delayed, absent) in all directions. Pelvic Tilt/Obliquity/Rotation: Patient presents (anterior, posterior) pelvic tilt with (forward, lateral, posterior) progression at the pelvis due to abnormal muscle tone. Patient requires (custom, contour) positioning to promote neutral postures. Leg Position: (internal, external) rotation noted with (minimal, moderate, maximal) (abduction, adduction) (flexor, extensor, mixed) tonal patterns present. Scoliosis: (lateral, minimal, moderate maximal) curvature noted to the (right, left) due to abnormal tone and poor motor control Lordosis/Kyphosis: (mild, moderate, maximal) (lordosis, kyphosis) noted. Head Position: (poor, fair, good) head control Shoulder/Scapula Position: (asymmetrical, symmetrical) when provided proper positional stability. ROM/Strength Limitations: presents with endurance/strength that are (increased,decreased,impaired) secondary to diagnosis. Range of motion is (increased,decreased, limited) in (upper, lower, all) extremities. NOTE: state specific ROM measurements if applicable UE/LE Function: (Active, Passive) movement in upper extremities is (increased, decreased, impaired) (right, left, bilaterally) with (minimal, moderate, maximal) deficits in (right, left, both) sides. On lower extremity exam, patient is ( severely limited and weak, is unable to stand or ambulate without supports, requires adaptive equipment for ambulation and requires full assist for standing, non-weight bearing, non-ambulatory) Transfers: (minimal, moderate, maximal) assist Activities of Daily Living (ADL’s): (minimal, moderate, maximal, total, full) assist with caregiver
SKIN CONDITION/INTEGRITY Susceptible to decubitus ulcers: Sensation: History of ulcers: Location: Stage: Ability to perform pressure relief:
EQUIPMENT TRIALS Various standing systems were considered that would be appropriate for patient’s medical condition. The standing systems explored included free text. Patient’s needs cannot be managed by the free text as it is not able to free text. After exploring the various options, it was determined that these standing systems did not meet the needs of the patient and family with regards to functional upright positioning and lower extremity weight bearing. It was determined that patient would best benefit from the free text. The new standing system will accommodate the current postural abnormalities, impaired motor control and physical limitations while providing optimal support, adapted positioning, and lower extremity weight bearing. This standing system meets all of the patient’s needs, the family’s needs and is the most fiscally and financially responsible choice. This standing system will be used in the (home, within the school system) for dependent upright positioning and proper postural support for weight bearing and functional participation. Goals of Recommended Equipment: (see Table B above) SUMMARY Patient is dependent for all postural support and requires a standing device to compensate for multiple medical conditions. Patient presents with a (weak trunk, limited extremity function, impaired mobility, abnormal tone, limited ability to control body, decreased range of motion). Patient requires a means for functional positioning in the home. Please consider these recommendations for the standing device justified below. Thank you for your time, EQUIPMENT PRESCRIBED (See Table A above) If you have any questions or concerns, please contact me at (xxx) xxx-xxxx. Therapist Physician, M.D. License # License # Date: Date:
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