AT ADVOCATE
Newsletter of the National
Assistive Technology Advocacy Project
A Project of Neighborhood Legal Services, Inc.
295 Main Street, Ste. 495 · Buffalo, New York 14203 · (716) 847-0650
(716) 847-0227 FAX · (716) 847-1322 TDD · e-mail: nls01@sprynet.com · Web Page:
http://www.nls.org
Supported by the National Institute on Disability and Rehabilitation Research,
U.S. Department of Education, Through a Subcontract with United Cerebral Palsy
Associations.
Volume III Issue 4
June/July 1998
Copyright 1998, Neighborhood Legal Services, Inc.
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In this issue......
REPORT WRITING: JUSTIFYING THE NEED FOR ASSISTIVE TECHNOLOGY
Introduction
Establishing Integrity of the Report
Getting Started: 5 Key Principles
Consider the Funding Source and the Criteria it will Follow
Drafting the Report
Conclusion
AT Court Watch: Second Circuit Denies Application for Rehearing in Desario
Case
Admiinistrative Hearings:Sometimes A Letter of Justification Becomes The
Basis For The Decision
REPORT WRITING: JUSTIFYING THE NEED FOR ASSISTIVE TECHNOLOGY
Previous issues of AT Advocate have discussed many different funding sources for AT, including Medicaid, Medicare, private insurance, the special education system, state vocational rehabilitation agencies and the Supplemental Security Income program’s Plan for Achieving Self Support.
Each of these funding sources
will generally require a report or letter of justification before approving funds for an
AT device. This report may come from a doctor, a physical therapist, an occupational
therapist, a speech pathologist, a special education teacher, a vocational rehabilitation
counselor or any number of other professionals. In this issue of AT Advocate, we
will discuss report writing as one means of justifying an AT request.
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ESTABLISHING THE INTEGRITY OF THE REPORT
The writer must impress upon the reader that his or her report is worthy of value and respect -- i.e., that it was written by a professional. This starts with the physical appearance of the document. The following should be a starting point of every report:
If the writer is a professional or works for an organization, the report should be written on appropriate letterhead.
GETTING STARTED: FIVE KEY PRINCIPLES OF REPORT WRITING
Although many funding sources will require completion of an agency form, a supporting letter of justification is always a good idea. There is no one special format for writing a report, but there are some general rules to follow:
Prioritize information, getting the important facts at the beginning of the report. Most readers pay more attention to the first sentence in a paragraph, to the first page of a document and so on. Present the most important pieces of information at the beginning of the document and in the topic or lead sentences of each paragraph.
Stay focused on one issue at a time to avoid confusing the reader. The writer often wants or needs to talk about several different issues in one report. Problems arise though when the writer jumps from topic to topic.
Strive for clarity. Use simple sentences and stay away from "$5 words." Avoid technical terms unless you must use them. The goal is to effectively communicate to a person who may not have the same professional background as the writer.
Educate the reader. Unless you know otherwise, assume the reader knows little about the individual’s disability or the requested equipment. Describe the person’s limitations in concrete functional terms and how the requested AT device will help to overcome those limitations.
Limit opinions to areas within the writer’s professional expertise. For example, if the writer is a vocational evaluator, he or she is qualified to give vocational opinions but not medical opinions. A writer who stays within his or her area of expertise will be more credible.
Consider this excerpt from a report written for a young man with cerebral palsy. Steve has used a manual wheelchair, but his physical therapist believes he now needs a power wheelchair and a new seating system. What is wrong with this excerpt?
"Steve, age 34, has a diagnosis of CP resulting from a TBI caused by an MVA when he was eight. He has a secondary diagnosis of scoliosis. He has used a manual chair all his life. He can no longer use his current chair because his seating system needs to be completely replaced. If Steve had a power chair, it would be easier for him to ambulate."
This excerpt presents several problems for the reader. Does the reader know what CP, TBI, and MVA all stand for? When the therapist uses the term "chair," will the reader know she is referring to a wheelchair? Is the writer asking for a new manual wheelchair, a new seating system or both? What is the significance of the statement about a power wheelchair? The following revised excerpt gives the reader a clearer picture of Steve’s needs:
"Steve, age 34, needs a power wheelchair and a new seating system. He has a diagnosis of cerebral palsy that resulted from a traumatic brain injury, which he sustained in a motor vehicle accident at age eight. He also suffers from scoliosis. Historically, Steve has used a manual wheelchair, but it no longer meets his needs. Steve’s scoliosis makes it physically impossible for him to use his arms to push a manual wheelchair. Steve also needs a new seating system. His present system does not meet his medical needs since his scoliosis has worsened. Also, his current seating system will not fit in a power wheelchair."CONSIDER THE FUNDING
SOURCE AND
THE CRITERIA IT WILL FOLLOW
Whether the funding source is an entitlement program like Medicaid or a private charity, there will be rules defining what AT is and what criteria must be met. Nearly all reports should address one of the following questions:
Medical necessity (e.g., Medicaid, Medicare, insurance): Is the equipment medical or remedial in nature, is it medically necessary and cost effective or the least costly medically appropriate alternative, is the request reasonable, and will it correct, cure and/or alleviate a medical problem?
Educational necessity (special education programs): Is the requested equipment necessary to ensure a free and appropriate education?
Vocational necessity (the state vocational rehabilitation agency): Is the requested AT necessary to allow the person to achieve a vocational goal or complete a program of vocational rehabilitation?
Consider the statements made by a physical therapist who wants Medicaid to pay for her patient’s wheelchair. Has the writer addressed the issue of "medical necessity?"
"John is a 14 year old boy, in ninth grade, with a diagnosis of cerebral palsy and asthma. He needs a power wheelchair which will allow him to conveniently travel to classes within his school. When John is at school, he is often late for classes because he cannot travel quickly in his manual wheelchair. With a power wheelchair, it would be much easier for him to get to his locker to exchange his books and go back to the cafeteria or other classes in a timely fashion. He would be better able to participate in school."
This writer has made two mistakes. First, by choice of language, the writer suggests that John’s need for the power wheelchair is based on "convenience," "quick" travel and "easier" movement around school. At no point does the writer state that the wheelchair is necessary for general mobility. Second, the writer is addressing "educational needs," not "medical needs." Although the ability to get around school and participate in school activities is relevant (note: the word "independence" appears in the federal Medicaid law), we recommend that this be referenced as supporting and not primary information. Finally, John’s therapist offered no information about the affects of his cerebral palsy on his mobility and overlooked the potential medical problems associated with asthma. Compare the statements made by a physical therapist who knows her audience:Introduce and establish the writer’s credentials.
In most cases, the writer is reporting as an expert. The writer can establish his/her expert credentials by describing: expertise, licenses, education, current job title and how long the writer has been doing this work. Additional information can include relevant classes or clinics taught by the writer or taken as a student, and any articles written that relate to the content of the report.
When Ms. Jones, a social worker for a group home, was asked to assist one of the residents who was asking for her family’s private insurance to purchase an augmentative communication device, she reported her credentials as follows:
"I have been employed by the Oakvale Community Residence since 1987. I graduated from the State University with both a bachelors and a masters degree in social work (in 1976 and 1978, respectively). Presently, I am working on my Doctorate in this field. I specialize in the needs of people who suffer from traumatic brain injuries and have been doing so since 1978. I currently lecture at the University School of Medicine and the Sociology Department on the social needs of individuals with Traumatic Brain Injuries (TBI)."
2. Establish the relationship with the patient or consumer.
Is the report based on a one-time consultation or weekly sessions with the patient over several years? A report will be more effective when it clarifies the nature of the relationship:
"Since Mary herself suffered a TBI, I took over her case when I started my employment with Oakvale in 1987. Currently, I see Mary twice each month for scheduled appointments and have done so for nearly 10 years. I have been responsible for making certain that Mary has access to a healthy environment that recognizes her psycho-social and medical needs. In this context, I have become very familiar with Mary’s communication problems."
Educate the reader about the patient’s disability.
If the writer is a doctor or other health care professional, the report provides an opportunity to educate the reader about the person’s disability. The writer should discuss the patient’s primary and secondary diagnosis, if any, his or her prognosis, and what complications affect the patient, and how. Since the patient is seeking AT which will overcome the effects of a disability, those effects should be described in functional terms. Although the non-medical professional cannot address medical issues, he or she can describe the functional consequences of the disability.
Consider these excerpts from the reports of Oakvale’s staff doctor, speech pathologist and social worker:
Doctor : "Mary suffers from the effects of a severe frontal lobe trauma she sustained in a motor vehicle accident. She experiences short term memory loss and her speech is extremely slow and slurred. She has a secondary diagnosis of quadraplegia, which is a result of the same accident. Her quadraplegia is accompanied by spasticity of the upper extremities and the loss of fine motor control. She also suffers from depression. According to the staff mental health counselor, her emotional prognosis is poor due to Mary’s inability to express herself."
Speech pathologist: "Mary’s receptive language skills are adequate to meet her daily needs. For example, she can understand basic directions, conversations, the television, etc. However, she is losing her expressive language skills due to her inability to speak and partake in conversation."
Social worker : "On the 25th of this month, Mary had an appointment with her dentist which I attended with her. It was almost impossible for her to explain the nature and extent of the pain in her mouth. Mary became very frustrated over her inability to explain herself. I have also personally witnessed times when Mary cried hysterically over little accidents because she could not communicate her need for help or intervention to keep the accident from happening in the first place."
Describe the type of equipment being requested.
Since it is common for vendors to refer to their equipment by model names or numbers, the report should give a specific description of the requested AT. The report should also describe any accessories that will be add-ons to the basic equipment. The following excerpt from the report of Mary’s speech pathologist contains the needed specifics:
"Based on my comprehensive augmentative communication evaluation which I describe below, I am recommending the following: a "Ready Voice 123" with a wheelchair mount, arm supports, female voice option and carrying case."
5. Describe any evaluations to determine need for AT.In many cases, the evaluations to determine the need for AT have been very comprehensive. Often, those evaluations have included trials on one or more pieces of equipment, including the one now recommended. The writer should describe any evaluations which have lead to the current recommendation. Again, Mary’s speech pathologist:
"During my evaluation, I tested Mary on four different augmentative communication devices, including the Ready Voice 123 ... [describes other devices]. [Explain why other three devices were determined to be inappropriate.] Based on this extensive evaluation and trial use, I determined that Mary has both the cognitive ability and the physical ability to use the Ready Voice to meet her communication needs."
6. State how the device meets the funding source’s criteria.
The writer must address whether the requested equipment is medically, educationally or vocationally necessary. With Medicaid, for example, the writer would address medical necessity and state why the equipment would cure or correct the effects of the patient’s condition, or prevent them from becoming worse or having new problems develop. Here is how Mary’s speech pathologist addresses this issue:
"The Ready Voice 123 is medically necessary because it will correct Mary’s inability to speak and aid Mary in preventing other health and safety issues from arising by allowing Mary to express herself. Through the use of the icons and the pre-programmed language, Mary should be able to recapture her expressive language skills and prevent any additional loss of her receptive language skills. For instance, at her dental appointment, Mary could have programmed the device to explain to the dentist which tooth bothered her, for how long and how intensely. The device will also be flexible enough to provide Mary spontaneous speech so she can address her immediate needs.
Because Mary is spastic, she has very little residual use in her arms. Therefore, when equipment is selected for Mary a primary consideration would be its ability to be modified to support Mary’s arm while being used. The Ready Voice 123 can be adapted with optional special equipment to support Mary’s arm so that she will have better control when selecting appropriate icons."
Let’s say that Mary is younger and in high school. How might this excerpt read then? Since we would be looking for the special education program to purchase the device, we need to show how the device will ensure an appropriate education.
"The Ready Voice 123 is necessary for Mary to receive an appropriate education. Mary’s receptive language skills are still appropriate for a young woman her age. However, her expressive language skills are decreasing because she cannot communicate effectively. This inability to express herself directly affects the quality of her education because her teachers and aides have almost no communication with Mary. Mary can speak, but her speech is slow and slurred and only understandable to familiar listeners who must ask Mary to constantly repeat herself. She has great difficulty asking questions regarding schoolwork or assignments that she does not understand. Mary cannot partake in classroom debates or discussions that aid a student’s ability to learn. Because she is not practicing self expression as a skill, her ability to functionally communicate is regressing. If this regression continues, the overall effect of her scholastic experience will be severely compromised."
The difference between the focus of these two paragraphs should be obvious even though they both address the need for the same piece of equipment. One paragraph discusses the need for self expression in order to engage in activities of daily living and maintain a certain degree of health; the other discusses Mary’s inability to actively participate in a learning experience.
Explain that the recommended device is the least costly alternative.
Remember, cost plays a big part in getting the AT one needs. The saying, "Never seek a Cadillac when a Chevy will do," is truly appropriate here. The writer must convince the funding source that they will not be spending money unwisely. Always approach any argument regarding the cost of an item as a consumer who is well-educated and has shopped around. Provide the funding source with information about different prices for similar models or different features. What is the warranty on the parts? Are there service contracts that might appeal to the funding source?
Here is what Mary’s speech pathologist has to say about least costly alternative:
"I considered less costly alternatives, but determined that none of those items could adequately meet Mary’s needs. The non-electronic "picture boards" were deemed inappropriate because their language level was not sufficiently sophisticated to meet the needs of a 32 year old woman. Further, the picture boards do not provide voice output and require the user to continually point to a picture to communicate. Mary’s spasticity would limit her ability to point to the pictures on the board. There are some electronic devices for under $1,000, including the ... [name them], but these would be inappropriate because they only allow for a fixed number of phrases and would not allow Mary to speak spontaneously."
"As noted above, I did consider three other devices which were all determined to be inappropriate for Mary. The cost for these three devices was in the same range as the cost for the Ready Voice 123, which will cost $6,899 with accessories. The ‘x device’ would cost $6,150; the ‘y device’ would cost $7,400 and the ‘z device’ would cost $8,100. In my opinion, the Ready Voice 123 is the least costly alternative that can adequately meet Mary’s communication needs. It also comes with a one year manufacturer’s warranty on parts and labor."
Use the concluding paragraph to restate the main points of the report.
All well-written documents end with an effective conclusion. It summarizes the preceding information and allows the writer an opportunity to briefly restate the case.
Every funding source for assistive technology will require some kind of report or letter of justification before funding will be approved for an AT device. Tragically, many reports fail to effectively communicate important information because their appearance or content is lacking. By following the simple suggestions in this article, the report writer will produce a report that is likely to result in the approval of funding. If the request for funding is denied, the report will make it more likely that the AT will be approved on appeal.
As always, we encourage
readers who have questions about the content of this article to call the AT Advocacy
Project at 716-847-0650. We will be happy to elaborate on any of the points made in this
article. This article appears on our web page (www.nls.org) at the National AT
Advocacy Project site.
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Second Circuit Denies Application for Rehearing in Desario Case
We previously reported on Desario v. Thomas, 139 F.3d 80 (2nd Cir. 2/24/98), in which the U.S. Court of Appeals for the Second Circuit held that Connecticut’s Medicaid program can limit the availability of AT to items which appear on an exclusive list. [See February-March 1998 issue of AT Advocate.] In late May 1998, the Second Circuit denied the plaintiffs’ Petition for Rehearing. Plaintiffs are expected to file a Petition for Certiorari with the United States Supreme Court.
[Copies of the Petition for Rehearing and the Amicus Curiae brief are available through the National AT Advocacy Project by calling Diane Dustin at 716-847-0655 ext. 218.]In Matter of Corey S. the New York Administrative Law Judge (ALJ) approved Medicaid funding, on appeal, for an Action Storm Power Wheelchair with Tarsys system (Tilt-in-Space). Note below how the physician’s letter was referenced from the fair hearing in this excerpt from his decision.
"The Agency's own packet contains the medical justification for the requested wheelchair and Tarsys Tilt system. A detailed letter was provided by the Appellant's representative, with a copy to the OHSM, regarding the Tarsys system. The letter is dated January 29, 1997, and is from the Appellant's physician, Dr. Sherif. The letter contains a long, detailed explanation of the medical necessity and cost effectiveness of the Tarsys system. Specifically, the Tarsys system is a modular system, which means that if the Appellant were to need additional components, they could be added to the existing system without having to purchase a new system. The letter further states that the Appellant has a diagnosis of Duchenne's muscular dystrophy and kyphoscoliosis, respiratory failure, severe restrictive respiratory disease requiring mechanical ventilation and oxygen dependent. Appellant also has a history of congestive heart failure, and suffers from severe muscle atrophy and weakness.
"The doctor states that the Appellant has a variety of symptoms which would benefit from a Tarsys system: By providing better trunk support, the tilt and space feature of the Tarsys system would improve Appellant's ability to breathe. It would also allow for secretion drainage in and around the lung tissue. The system would provide proper trunk support which would in turn provide for optimal medical effects from the Appellant's ventilator.
"The letter goes on to state that the Appellant's overall weakness prevents him from repositioning himself, leading to skin breakdown and pressure ulcers in the sacral and hip area. These recurring medical problems are costly and could be alleviated with the requested system. Dr. Sherif maintains that the best and most cost efficient method of addressing these medical problems is an electrical system that would allow the Appellant to reposition himself. A Tarsys system, according to the physician, would meet this need. The tilt feature would allow Appellant to independently provide pressure relief to his buttock and sacrum by distributing his weight over a larger area if needed. The system provides increased sitting tolerance and control of skin integrity by allowing for different body orientation of space from fully upright to varying degrees of backward tilt. Dr. Sherif notes that the Appellant cannot use a reclining system due to hip flexion contraction, and that such a system would not have the same medical effects on skin integrity as the tilt in space system.
"The doctor continues in detail to list other conditions which would benefit from the Tarsys system, specifically, the Appellant's poor spinal support which contributes to difficulty in eating, swallowing and overall poor circulation. Appellant has experienced weight loss because he gets tired from the effects of poor spinal support. The letter states that with the Tarsys system, Appellant will be able to tilt back and rest during the day and decrease the effect of having to hold his body upright against gravity. Dr. Sherif contends that Appellant's overall circulation will benefit because it will not be inhibited by his trunk collapsing on his belt. When Appellant eats or socializes, he can sit upright and erect in the chair and will not become overly tired.
"Dr. Sherif also cites the ability to raise and lower Appellant's legs to prevent skin breakdown and reduce swelling as an additional medical benefit. This ability is needed, according to the doctor, to allow fluid to return to the heart and reduce swelling.
"The doctor concludes by stating that as a Board Certified pulmonologist and critical care specialist and Assistant Professor at the University of Buffalo, and Appellant's physician since 1993, it is his professional opinion ‘that a system that allows Corey to control the effect of gravity on his body is medically necessary because it will aid in the prevention of skin breakdown, will aid in the drainage of secretions and prevent swelling. It will also maximize his lung capacity, offer correct spinal support and limit unnecessary exertion that can have detrimental effects on his heart and nutritional needs.’
"Although a copy of this letter was provided to OHSM, no response or rebuttal has been received.
"The above clearly establishes that the Tarsys system is medically necessary for the Appellant. The physician's documentation and the documentation from the provider establish that this system is modular and cost effective."
For copies of this fair hearing decision, contact
Diane Dustin at (716) 847-0655 ext. 218.
Update on The National Assistive Technology Resource Library
We have designed a word-searchable digest, using computer technology, to store and retrieve hearing decisions and other administrative documents. We also have indexed more than 250 documents from more than 70 pending and decided court cases. All documents are available through our AT Resource Library. Please send us your hearing decisions, briefs and other documents involving AT.
Please send information to:
TEL: (716) 847-0650 Handsnet: HN0627
Attn.: Diane Dustin
FAX: (716) 847-0227 e-mail: nls01@sprynet.com
Neighborhood Legal Services, Inc.
TDD: (716) 847-1322
Ellicott Square Building
Web Page: http://www.nls.org
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The AT Advocacy Project
will provide nationwide services to PAAT projects including technical assistance to
advocates wanting to access funding for assistive technology for individuals with
disabilities.
- AT Funding through the Americans with Disabilities Act (ADA)
- Final IDEA Reauthorization Regulations
NOTE: The AT Advocate is now issued bi-monthly