How to write a successful Letter of Medical Necessity (L.M.N.) Sally Mallory, PT, ATP

How to write a successful Letter of Medical Necessity (L.M.N.) Sally Mallory, PT, ATP

The Problem High numbers of funding requests for DME are denied. CMS funding levels are being reduced with expense cutting Many denials on first review are due to procedural errors or simple omissions in funding requests Lack of sufficient or compelling Medical Necessity documentation Increased focus on lower cost alternative LMN s that do not paint the complete picture of the client s seating, positioning and mobility needs!

CMS Definition of Medically Necessary Medical Necessity as defined by CMS and, by trickle down effect, State Medicaid systems and most third party insurance coverage: The service or benefit will, or is reasonably expected to, prevent the onset of an illness, condition, or disability The service or benefit will, or is reasonably expected to, reduce or ameliorate the physical, mental, or developmental effects of an illness, condition or disability. The service or benefit will assist the individual to achieve or maintain maximum functional capacity in performing daily activities taking into account both the functional capacity of the individual and those functional capacities that are appropriate for individuals of the same age.

Advocate As defined by www.merriam-webster.com 1. One that pleads the cause of another; specifically : one that pleads the cause of another before a tribunal or judicial court 2. One that defends or maintains a cause or proposal 3. One that supports or promotes the interests of another

What is the problem? Incomplete client presentation Incomplete matt assessment Incomplete Medical/ Functional justification Absence of other equipment evaluation No supporting documentation Absence of consequences if denied

LMN s Essential Components 1. You are the professional! 2. Paint a Picture of your client 3. If a current user, describe current equipment, why it is not meeting the clients needs. 4. Describe what the Therapeutic Goals are for the new equipment 5. Describe Trial and Use of equipment evaluated 6. Describe the Clinical Reasoning for the equipment selected 7. Most important! Describe what would happen in the absence of recommended equipment

1) You are the Professional Document is a direct reflection of your professional persona Reflects your knowledge of this client How often do you see them, for what purpose, how long have you known them. What is your expertise? Include credentials

2) Paint a Picture Include: 1. Name 2. Age 3. Primary diagnosis and onset 4. Secondary diagnosis, list all that apply 5. Primary funding source Matt Assessment: Describe all physical findings of the matt assessment. Deformities, redness, spasticity, etc Where did you have to use hands to support patient for posture

2) Paint a Picture Complete clinical presentation and level of function of client including educational, social/emotional development cognitive skills, ambulation, ADL s, mobility, R.O.M. at joints, strength, endurance, tone, reflexes, school/home/work requirements, transportation, peer interactions Describe your client s seating, positioning mobility and medical needs. Do not list or describe any information that is not relevant to the request.

3) Current User Describe current mobility equipment, condition, age, prior repairs Describe current seating and positioning equipment, age, condition Who provided current chair? Any specific lifestyle reasons that current equipment does not meet? Has their medical condition changed?

3) Current User Describe physical presentation of client when using current equipment Describe any issues and/or problems client has had with current equipment Likes, dislikes. What worked, what didn t work

4) Therapeutic Goals Be specific as to what your therapeutic goals are for the new equipment. Increased sitting tolerance, ability to interact/engage Therapeutic pelvic positioning and body alignment Tone management Improved head control Improved upper body control Improved distal function What was not achieved with prior equipment

5) Trial/Evaluation What type/brand of wheelchairs and seating were considered and rejected Type/options considered What were the shortcomings Clinical reasoning for rejection. What wheelchairs were actually evaluated with client. Funding sources prefer at least 2 documented options Type/model evaluated Reasons as to why they were approved or rejected Describe how the client presented in the selected wheelchair Pictures of client in the chair Posture and/or functional improvements All pertinent observations

5) Trial/Evaluation Clinical reasoning as to why you selected the specific wheelchair and seating that is being recommended. What clinical/tone changes were observed How the client presented in the chair Empirical data (increased sitting time, skin condition) How the equipment met the client s needs

5) Trial/Evaluation Be specific on recommended equipment Sample wording: The following specific items described are the exact items that this person needs. The specifications, brands and models themselves should not be changed. They have been chosen with great care for function, durability, ease of use, compatibility, accessibility and for this individual's own specific medical and therapeutic needs.* * Karen M Kangas OTR/L

6) Clinical Reasoning All Seating and Mobility equipment should be prescribed only to meet an identified Clinical / Therapeutic/ Positioning Need. Safety is not a medical/clinical need Comfort is not a medical need What Functional improvement does the device provide.

6) Clinical Reasoning Chair and Positioning Components Clinical Reasoning for Tilt-in-Space chair * Pressure Relief. Reduction of pressure at I.T. s Improved respiration/gastric motility Improved therapeutic posture Reduced fatigue (Increased seating tolerance) * Chan A, Heck CS The effects of tilting the seating position of a wheelchair on respiration, posture, fatigue, voice volume and exertion outcomes in individuals with advanced multiple sclerosis. J Rehabil Outcomes Meas. 1999;3:1 14.

6) Clinical Reasoning Recline Recline systems provide a change in seatto-back angle orientation while maintaining a constant seat angle with respect to the ground. Clinical reasoning Accommodate hip angles and deformities Positioning for feeding Pressure relief Position for improved respiration Postural relief Catheterization

6) Clinical Reasoning Describe each seating and positioning component required (Head Supports, A.T.S., Lateral Thoracic, Pelvic Positioning, etc) to achieve therapeutic seating and/or postural support Provide medically necessary reasoning as to why each item is needed Funding Agency s concerns: Safe or Safety is not a medically necessary reason to approve equipment funding Comfort is not a medical necessity as defined by CMS. Increased Seating Tolerance IS considered a medical necessity

6) Clinical reasoning Pelvic Positioning Belts helps to provide and maintain proper neutral hip and pelvic positioning on the seat cushion 4-point: this unique design helps to maintain neutral pelvic positioning, discourage and corrects posterior pelvic tilt and aids in preventing anterior displacement of the I.T. s. This was the only positioning belt able to provide and maintain neutral pelvic positioning.

6) Clinical reasoning Hip Guides Provides medial pelvic positioning and lower extremity positioning on the seat cushion. Provides lateral pelvic alignment and helps provide upper body stability

6) Clinical reasoning Foot Positioning/Foot bed Maximize foot print/loading surfaces Minimize skin breakdown Tone control Injury prevention due to extensor tone Improved lower extremity alignment Aids in proper joint alignment

6) Clinical reasoning Lateral Thoracic Supports to provide lateral trunk control, stability, mid line positioning and proper postural alignment Help provide correction to flexible curved postures (3 point support) Aid in providing pelvic stability by aligning the trunk over the pelvis

6) Clinical reasoning Shoulder Harness/ H Harness/ Butterfly Harness/Chest Strap Provides anterior support of the trunk to promote upper body stability Provides anterior upper trunk support when patient has postural fatigue due to poor tone Enhances distal function of upper extremities

6) Clinical reasoning Head Supports Provides head/neck support for clients with poor head control Provides lateral support for clients with lateral head control issues Provides stable support for improved field of vision

6) Clinical reasoning Canopy/Sunshade Client has been prescribed (Brand) medication for tone/spasticity management. This medication creates extreme photosensitivity when client is exposed to direct sunlight, causing severe sunburns and skin tissue damage Client has been prescribed (brand) medication. This medication generates a strong allergic reaction when skin is exposed to direct sunlight Exposure to sun increases body temperature which can set off seizure activity.

6) Clinical Reasoning Lightweight, easy to use mobility base. Due to user s restricted access to his/her home and the need to maintain therapeutic positioning for improved upper body function

7) What if? Comparison The last but critical component of the LMN that completes the picture of the client Make sure to describe your Therapeutic Goals Describe on your terms what would/could happen to the client in the absence of any recommended component or equipment. Describe the possible complication(s) and negative outcome(s) that may occur if critical components are not approved for funding

7) What if? Example: In absence of the lightweight tilt in space mobility base, Samantha has a higher risk of developing pressure sores and skin breakdown due to increased pressure at the pelvis due to her inability to independently shift posture and relief pressure away from the ischial tuberosities.

Supporting Documentation Existing equipment: Take pictures and/or video of client in current equipment. Describe the problems. Likes, dislikes Take pictures and video during equipment trials. Describe the physical and postural changes experienced during the trial Include copies of any supporting clinical trials, case studies or research to support your case

Additional Notes You are the professional! Make sure to clearly document it. Does the document look professional? Review prior to submittal. Does the document support the medical/functional needs of the request? Is it signed and dated? In some states, case reviewers do not have a clinical/medical background. Use appropriate language when writing your LMN s If request is denied, contact manufacturer for additional information and support Re-submit and/or appeal! Be an advocate for your client

Additional Notes Transit Transit option: Medicare/Medicaid/Third Party will not fund it in majority of cases. Safety is not a medical necessity! Be creative. Transit: Positioning components are NOT Restraint Devices! Transit Tips: Provides four easy to identify securement points and a crash tested system, allowing the patient to use the wheelchair as a passenger seat during transportation while maintaining proper therapeutic positioning. Complies with SAE J2249 and ANSI/RESNA WC19 standards. Look for alternative funding. Schools districts will sometimes pay for them.

Thank you for your time today! Make a difference in someone s life today For additional questions: Sally Mallory, PT, ATP Convaid sally@convaid.com 469-704-5212

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