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Letter of Medical Necessity:

The above patient has been under my care and will be in need of the prescribed orthopedic product. This product was prescribed to aid and/or accelerate the rehabilitation process and is deemed medically necessary.

The indicated product is used to:
Length of need:
Prosthetic Device (Select Device Type and K Level)
K Level (select one):

K Level is the activity level for an Amputee

Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance. Prosthesis does not enhance quality of life or mobility.
Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator.
Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs, or uneven surfaces. Typical of the limited community ambulator.
Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.
Level 4: Has the ability or potential for ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the child, active adult, or athlete.

Custom Prosthetic Referrals

require detailed chart notes describing why the device is needed.

New & Replacement Prosthetic Referrals
require a Prosthetic Evaluation Form. If you need one of these forms or have
additional questions, please call our office at (210) 290-9225

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