C300 Corpus

advertisement

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009

Bases & Seating System

C300 PS

C300 Corpus

C300 Corpus Tilt (WIP)

C300 Corpus Jr.

C350 PS

C350 Corpus

K300 PS Jr

K450 MX

C400 Corpus

C400 Corpus Jr

C400 Lowrider

C400 VS Jr. Stander

C500 Corpus

Street

HD3

C500 Lowrider

C500 RS (N/A)

C500 VS Stander

C300 PS

The C300 is a compact front wheel drive wheelchair base with programmable electronics. It has an adjustable suspension and quiet, powerful motors. It has large front and rear casters for excellent ride and maneuverability both indoors and outdoors. It supports a variety of seating systems, power seat functions, and driving controls to meet individual needs.

The PS is a durable, adjustable tubular seat frame with 1” tube diameter to accommodate other aftermarket seating. The frame is inherently growable in width and depth from 16 – 22” so that it can be customized and adapted to the client needs.

C300 Corpus

The C300 is a compact front wheel drive wheelchair base with programmable electronics. It has an adjustable suspension and quiet, powerful motors. It has large front and rear casters for excellent ride and maneuverability both indoors and outdoors. It supports a variety of seating systems, power seat functions, and driving controls to meet individual needs.

The Corpus is a modular, ergonomic seating system built to accommodate changes in CLIENT and/or growth. The seat depth grows from 14"-22", and the width grows from 17-23", without the need to change the seat frame. This allows a custom fit for the specific individual, and provides accommodation for growth, orthopedic deformities, and significant weight gain or loss.

The Corpus can accommodate a variety of power seat functions, including tilt, recline, power elevating legrests, and vertical seat elevation. These functions can also easily be added for to meet their future medical needs without shipping the chair back to the manufacturer or having to purchase a new base, saving time, money, and inconvenience to CLIENT.

The basic Corpus seating system can be adjusted for seat depth, seat width, backrest size, lower leg length, footplate angle, seat to back angle, armrest height and angle, etc. The backrest width can differ from the seat width, which is unique to the Corpus seating system, allowing a truly custom fit In addition, the system comes standard with three lumbar pads, which can be adjusted to follow the person’s natural spinal curves and/or to provide posterior pelvic stabilization. It also comes with mild, modular, removable lateral supports, to provide seamless but stable midline positioning. More aggressive lateral trunk and thigh supports can be easily added to the seating system.

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009

C300 Corpus Jr.

TOP

The C300 is a compact front wheel drive wheelchair base with programmable electronics. It has an adjustable suspension and quiet, powerful motors. It has large front and rear casters for excellent ride and maneuverability both indoors and outdoors. It supports a variety of seating systems, power seat functions, and driving controls to meet individual needs.

The Corpus Jr. is an ergonomic, modular customizable seating system in pediatric or junior sizing. The seat depth grows from 13 -18" without additional parts. The seat frame can grow to

23" width and 22" depth. This allows a custom fit for the specific individual, and provides accommodation for growth, orthopedic deformities, and significant weight gain or loss. The

Corpus Jr. can accommodate a variety of power seat functions, including tilt, recline, power elevating legrests, and vertical seat elevation. These functions can also easily be added for to meet their future medical needs without shipping the chair back to the manufacturer or having to purchase a new base, saving time, money, and inconvenience to CLIENT.

The basic Corpus seating system can be adjusted for seat depth, seat width, backrest size, lower leg length, footplate angle, seat to back angle, armrest height and angle, etc. The backrest width can differ from the seat width, which is unique to the Corpus seating system, allowing a truly custom fit In addition, the system comes standard with three lumbar pads, which can be adjusted to follow the person’s natural spinal curves and/or to provide posterior pelvic stabilization. It also comes with mild, modular, removable lateral supports, to provide seamless but stable midline positioning. More aggressive lateral trunk and thigh supports can be easily added to the seating system.

C350 PS

The C350 is a compact rear wheel drive wheelchair base with programmable electronics. It has an adjustable four-wheel independent suspension and quiet, powerful motors. It has large front casters for excellent ride and maneuverability both indoors and outdoors. Anti-tippers are mounted in the rear of the wheelchair base to improve stability and keep the wheelchair from tipping if it is in an unstable position. It is designed for active users who need a durable and reliable wheelchair to meet their daily mobility needs. It supports a variety of seating systems, power seat functions, and driving controls to meet individual needs.

The PS is a durable, adjustable tubular seat frame with 1" tube diameter to accommodate other after-market seating. The frame is inherently growable in width and depth from 16 – 22" so that it can be customized and adapted to client needs.

C350 Corpus

The C350 is a compact rear wheel drive wheelchair base with programmable electronics. It has an adjustable four-wheel independent suspension and quiet, powerful motors. It has large front casters for excellent ride and maneuverability both indoors and outdoors. Anti-tippers are mounted in the rear of the wheelchair base to improve stability and keep the wheelchair from tipping if it is in an unstable position. It is designed for active users who need a durable and reliable wheelchair to meet their daily mobility needs. It supports a variety of seating systems, power seat functions, and driving controls to meet individual needs.

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009

The Corpus is a modular, ergonomic seating system built to accommodate changes in CLIENT and/or growth. The seat depth grows from 14"-22", and the width grows from 17-23", without the need to change the seat frame. This allows a custom fit for the specific individual, and provides accommodation for growth, orthopedic deformities, and significant weight gain or loss.

The Corpus can accommodate a variety of power seat functions, including tilt, recline, power elevating legrests, and vertical seat elevation. These functions can also easily be added for to meet their future medical needs without shipping the chair back to the manufacturer or having to purchase a new base, saving time, money, and inconvenience to CLIENT.

The basic Corpus seating system can be adjusted for seat depth, seat width, backrest size, lower leg length, footplate angle, seat to back angle, armrest height and angle, etc. The backrest width can differ from the seat width, which is unique to the Corpus seating system, allowing a truly custom fit In addition, the system comes standard with three lumbar pads, which can be adjusted to follow the person’s natural spinal curves and/or to provide posterior pelvic stabilization. It also comes with mild, modular, removable lateral supports, to provide seamless but stable midline positioning. More aggressive lateral trunk and thigh supports can be easily added to the seating system .

K300 PS Jr.

TOP

The K300 is a compact front wheel drive wheelchair base with programmable electronics. It has an adjustable suspension and quiet, powerful motors. It has large front and rear casters for excellent ride and maneuverability both indoors and outdoors. It supports a variety of driving controls to meet individual needs. The PS Jr. is a durable, adjustable tubular seat frame with 1” tube diameter to accommodate other aftermarket seating. The frame is inherently growable in width from 11-16” and depth from 10-18” so that it can be customized and adapted to client needs. Its design includes height and rotationally adjustable armrests as well as the Uni-track system for lateral supports and other accessories, making the system extensively customizable.

Performance "S" Package

The performance "S" package is a high speed option for the C500 base. It includes high speed motors that allow the wheelchair speeds of 6.5 mph, 120 amp electronics, and an Enhanced

Steering Performance (ESP) module to improve tracking of the base to allow improved tracking at higher speeds. This higher performance is needed for the active user to have quicker responsiveness and speed across various terrains, through busy intersections, and for an active lifestyle.

R-Net Programming Key

This programmer will allow the drive parameters of the controller to be modified to customize driving for optimal access. Parameters such as speed and acceleration in forward, reverse and turning can be changed, as well as the sensitivity and response of the joystick and power required to move. The programmer allows fine tuning to optimize driving and can be used to reprogram for changing needs.

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009

K450 MX

TOP

The K450 MX is a power wheelchair which offers the unique function of moving CLIENT to the floor. The K450 MX provides a large range of vertical mobility, in addition to the traditional 2 dimensional movement provided by other power wheelchairs. The seat moves forward and down by the press of a switch or via any wheelchair control, enabling CLIENT to get to the floor while remaining seated. The seat to floor function not only helps incorporate children into peer activities, but also enables CLIENT to transfer independently to the floor, or to any other surface.

Providing a means for independent transfers in and out of the wheelchair is a medical necessity for individuals of all ages. In addition to improving independence, the seat to floor feature also promotes safety by reducing handling by unqualified people and lowering the level of transfer.

The elevating seat allows CLIENT to access various heights – supplementing upper extremity weakness and range limitations, thereby increasing access for performing MRADL tasks and further improving independence. The K450 base has the option to add 45° power tilt which will provide postural stability (facilitating trunk and head control) and appropriate pressure relief

(reducing the risk of skin breakdown) – ultimately increasing overall sitting tolerance.

The K450 MX base is also capable of negotiating small obstacles and soft terrain, such as grass or gravel, so CLIENT can participate in ADLs with peers in the home, school, yard or on the playground. Additionally, it offers all-wheel suspension which further promotes safety by reducing the amount of forces absorbed through CLIENT’s body while navigating various terrains and controlling abnormal tone responses.

The MX seat will grow with the child for years, from 10"x10" to 16"x18". It offers manual adjustable legrests, height adjustable armrests, and seat depth adjustability at no charge. All standard seating accessories are available, such as headrest, thoracic lateral supports and hip guides for improved positioning. As an alternative, a tubular seat frame may be used to accept after-market seating systems.

Permobil also offers one time free growth kit on this pediatric system to accommodate children as they grow, making the system more economical in the future.

C400 Corpus

TOP

The C400 is a sturdy front-wheel drive power wheelchair base with programmable electronics. It has excellent suspension (including drive wheel suspension) and a compact base for indoor and outdoor maneuverability. It has excellent stability, so it can support a variety of seats and power seat functions.

The Corpus is a modular, ergonomic seating system built to accommodate changes in CLIENT and/or growth. The seat depth grows from 14"-22", and the width grows from 17-23", without the need to change the seat frame. This allows a custom fit for the specific individual, and provides accommodation for growth, orthopedic deformities, and significant weight gain or loss.

The Corpus can accommodate a variety of power seat functions, including tilt, recline, power elevating legrests, and vertical seat elevation. These functions can also easily be added for to meet their future medical needs without shipping the chair back to the manufacturer or having to purchase a new base, saving time, money, and inconvenience to CLIENT.

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009

The basic Corpus seating system can be adjusted for seat depth, seat width, backrest size, lower leg length, footplate angle, seat to back angle, armrest height and angle, etc. The backrest width can differ from the seat width, which is unique to the Corpus seating system, allowing a truly custom fit In addition, the system comes standard with three lumbar pads, which can be adjusted to follow the person’s natural spinal curves and/or to provide posterior pelvic stabilization. It also comes with mild, modular, removable lateral supports, to provide seamless but stable midline positioning. More aggressive lateral trunk and thigh supports can be easily added to the seating system.

C400 Corpus Jr.

TOP

The C400 is a sturdy front-wheel drive power wheelchair base with programmable electronics. It has excellent suspension (including drive wheel suspension) and a compact base for indoor and outdoor maneuverability. It has excellent stability, so it can support a variety of seats and power seat functions.

The Corpus Jr. is an ergonomic, modular customizable seating system in pediatric or junior sizing. The seat depth grows from 13 -18" without additional parts. The seat frame can grow to

23" width and 22" depth. This allows a custom fit for the specific individual, and provides accommodation for growth, orthopedic deformities, and significant weight gain or loss. The

Corpus Jr. can accommodate a variety of power seat functions, including tilt, recline, power elevating legrests, and vertical seat elevation. These functions can also easily be added for to meet their future medical needs without shipping the chair back to the manufacturer or having to purchase a new base, saving time, money, and inconvenience to CLIENT.

The basic Corpus seating system can be adjusted for seat depth, seat width, backrest size, lower leg length, footplate angle, seat to back angle, armrest height and angle, etc. The backrest width can differ from the seat width, which is unique to the Corpus seating system, allowing a truly custom fit In addition, the system comes standard with three lumbar pads, which can be adjusted to follow the person’s natural spinal curves and/or to provide posterior pelvic stabilization. It also comes with mild, modular, removable lateral supports, to provide seamless but stable midline positioning. More aggressive lateral trunk and thigh supports can be easily added to the seating system.

C400 Lowrider

TOP

The C400 is a sturdy front-wheel drive power wheelchair base with programmable electronics. It has excellent suspension (including drive wheel suspension) and a compact base for indoor and outdoor maneuverability. It has excellent stability, so it can support a variety of seats and power seat functions. Its seating system has a 16” seat to floor height for accessibility and transfer.

The Corpus is a modular, ergonomic seating system built to accommodate changes in CLIENT and/or growth. The seat depth grows from 14"-22", and the width grows from 17-23", without the need to change the seat frame. This allows a custom fit for the specific individual, and provides accommodation for growth, orthopedic deformities, and significant weight gain or loss.

The Corpus can accommodate a variety of power seat functions, including tilt, recline, power elevating legrests, and vertical seat elevation. These functions can also easily be added for to

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009 meet their future medical needs without shipping the chair back to the manufacturer or having to purchase a new base, saving time, money, and inconvenience to CLIENT.

The basic Corpus seating system can be adjusted for seat depth, seat width, backrest size, lower leg length, footplate angle, seat to back angle, armrest height and angle, etc. The backrest width can differ from the seat width, which is unique to the Corpus seating system, allowing a truly custom fit In addition, the system comes standard with three lumbar pads, which can be adjusted to follow the person’s natural spinal curves and/or to provide posterior pelvic stabilization. It also comes with mild, modular, removable lateral supports, to provide seamless but stable midline positioning. More aggressive lateral trunk and thigh supports can be easily added to the seating system.

C400 VS Jr.

TOP

The C400 is a sturdy front-wheel drive power wheelchair base with programmable electronics. It has excellent suspension (including drive wheel suspension) and a compact base for indoor and outdoor maneuverability. It has excellent stability, so it can support a variety of seats and power seat functions.

The VS (Vertical System) is a complete powered seating system with full recline, power tilt, elevating legrests, vertical seat elevation and various ways of achieving the standing position.

Standing is accomplished from either a seated, semi-reclined, or fully reclined position. Reclineto-stand allows the body to be extended before all of the weight is transferred onto the feet and mimics standing features on tilt tables or supine standers and reduces buckling at the knees or slipping at the hips. The benefits of standing in a power wheelchair are many:

1) Allows weight bearing multiple times a day, which is essential to reducing osteoporosis, reducing the risk of joint contractures, facilitating normal bone and joint development, reduction of depression and other psycho-social issues.

2) Removes pressure from the scapulae, sacrum, coccyx, and ischial tuberosities

3) Assists with digestion, respiration, and bowel/bladder management.

4) Slowly coming to stand from reclined position, stopping as needed, can reduce the risk of orthostatic hypotension, control abnormal or primitive reflexes, and provide spasticity management

5) Provides improved compliance to standing program by having the standing feature readily available

6) Improves access to toilets, sinks, counters, cabinets when using the stand and drive feature

7) Improves psycho-social status – allowing the user to see eye-to-eye with peers

8) Supine standing requires least amount of head and trunk controls

9) Increases reach and access, and enhances interaction with others

10) Allows user to stand and drive making standing more functional and facilitating independent performance of MRADLs

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009

C500 Corpus

The C500 is a powerful front wheel drive wheelchair base with rugged dual independent

TOP

suspension and programmable electronics. It is made to handle well in indoor and rugged outdoor terrain. The C500 can support a variety of seating systems, power seat functions, and alternate driving controls to meet the individual needs of CLIENT, and it is easily adapted for growth, changes in medical needs and pressure relief, and for alternative driving access.

The Corpus is a modular, ergonomic seating system built to accommodate changes in CLIENT and/or growth. The seat depth grows from 14"-22", and the width grows from 17-23", without the need to change the seat frame. This allows a custom fit for the specific individual, and provides accommodation for growth, orthopedic deformities, and significant weight gain or loss.

The Corpus can accommodate a variety of power seat functions, including tilt, recline, power elevating legrests, and vertical seat elevation. These functions can also easily be added for to meet their future medical needs without shipping the chair back to the manufacturer or having to purchase a new base, saving time, money, and inconvenience to CLIENT.

The basic Corpus seating system can be adjusted for seat depth, seat width, backrest size, lower leg length, footplate angle, seat to back angle, armrest height and angle, etc. The backrest width can differ from the seat width, which is unique to the Corpus seating system, allowing a truly custom fit In addition, the system comes standard with three lumbar pads, which can be adjusted to follow the person’s natural spinal curves and/or to provide posterior pelvic stabilization. It also comes with mild, modular, removable lateral supports, to provide seamless but stable midline positioning. More aggressive lateral trunk and thigh supports can be easily added to the seating system.

C500 Lowrider

The C500 is a powerful front wheel drive wheelchair base with rugged dual independent suspension and programmable electronics. It is made to handle well in indoor and rugged

TOP

outdoor terrain. The C500 can support a variety of seating systems, power seat functions, and alternate driving controls to meet the individual needs of CLIENT, and it is easily adapted for growth, changes in medical needs and pressure relief, and for alternative driving access. Its seating system has a 16" seat to floor height for accessibility and transfer.

The Corpus is a modular, ergonomic seating system built to accommodate changes in CLIENT and/or growth. The seat depth grows from 14"-22", and the width grows from 17-23", without the need to change the seat frame. This allows a custom fit for the specific individual, and provides accommodation for growth, orthopedic deformities, and significant weight gain or loss.

The Corpus can accommodate a variety of power seat functions, including tilt, recline, power elevating legrests, and vertical seat elevation. These functions can also easily be added for to meet their future medical needs without shipping the chair back to the manufacturer or having to purchase a new base, saving time, money, and inconvenience to CLIENT.

The basic Corpus seating system can be adjusted for seat depth, seat width, backrest size, lower leg length, footplate angle, seat to back angle, armrest height and angle, etc. The backrest width can differ from the seat width, which is unique to the Corpus seating system, allowing a truly custom fit In addition, the system comes standard with three lumbar pads, which can be adjusted

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009 to follow the person’s natural spinal curves and/or to provide posterior pelvic stabilization. It also comes with mild, modular, removable lateral supports, to provide seamless but stable midline positioning. More aggressive lateral trunk and thigh supports can be easily added to the seating system.

C500 VS

The C500 is a powerful front wheel drive wheelchair base with rugged dual independent

TOP

suspension and programmable electronics. It is made to handle well in indoor and rugged outdoor terrain. The C500 can support a variety of seating systems, power seat functions, and alternate driving controls to meet the individual needs of CLIENT, and it is easily adapted for growth, changes in medical needs and pressure relief, and for alternative driving access.

The VS (Vertical System) is a complete powered seating system with full recline, power tilt, elevating legrests, vertical seat elevation and various ways of achieving the standing position.

Standing is accomplished from either a seated, semi-reclined, or fully reclined position. Reclineto-stand allows the body to be extended before all of the weight is transferred onto the feet and mimics standing features on tilt tables or supine standers and reduces buckling at the knees or slipping at the hips. The benefits of standing in a power wheelchair are many:

1) Allows weight bearing multiple times a day, which is essential to reducing osteoporosis, reducing the risk of joint contractures, facilitating normal bone and joint development, reduction of depression and other psycho-social issues.

2) Removes pressure from the scapulae, sacrum, coccyx, and ischial tuberosities

3) Assists with digestion, respiration, and bowel/bladder management.

4) Slowly coming to stand from reclined position, stopping as needed, can reduce the risk of orthostatic hypotension, control abnormal or primitive reflexes, and provide spasticity management

5) Provides improved compliance to standing program by having the standing feature readily available

6) Improves access to toilets, sinks, counters, cabinets when using the stand and drive feature

7) Improves psycho-social status – allowing the user to see eye-to-eye with peers

8) Supine standing requires least amount of head and trunk controls

9) Increases reach and access, and enhances interaction with others

10) Allows user to stand and drive making standing more functional and facilitating independent performance of MRADLs.

Street Corpus

The Street is a powerful rear-wheel drive base with adjustable four-wheel independent

TOP

suspension. It is designed for active users who need a durable, reliable and high performing wheelchair to meet their daily mobility needs. It is available in many sizes with choice of power seat functions and alternate drive controls to ensure that future needs can be accommodated should CLIENT’s medical or functional needs change.

The Corpus is a modular, ergonomic seating system built to accommodate changes in CLIENT and/or growth. The seat depth grows from 14"-22", and the width grows from 17-23", without the need to change the seat frame. This allows a custom fit for the specific individual, and

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009 provides accommodation for growth, orthopedic deformities, and significant weight gain or loss.

The Corpus can accommodate a variety of power seat functions, including tilt, recline, power elevating legrests, and vertical seat elevation. These functions can also easily be added for

CLIENT needing these to meet their medical needs in the future without shipping the chair back to the manufacturer, saving time and inconvenience to CLIENT.

The basic Corpus seat can be adjusted for seat depth, seat width, backrest size, lower leg length, footplate angle, seat to back angle, armrest height and angle, etc. The backrest width can be different from the seat width, which is unique to the Corpus seating system, allowing a truly custom fit In addition, the system comes standard with three lumbar pads, which can be adjusted to follow the person’s natural spinal curves and/or to provide posterior pelvic stabilization. It also comes with mild, modular, removable lateral supports, to provide seamless but stable midline positioning. More aggressive lateral trunk and thigh supports can be easily added to the seating system.

Chairman HD3

TOP

The Chairman HD3 is a heavy duty power wheelchair with a 400 lb. weight capacity and larger seat size options. The reinforced base is wider for enhanced stability. The backrest is secured to a reinforced frame. The seat is deeper, wider and higher, and is naturally adjustable for different size requirements. The seat frame is stronger, the foot plate more solid, and the calf supports are also larger to provide proper fit and comfort.

The HD3 seating system uses a reinforced Corpus seating system with larger seat sizes. It comes standard with power recline, adjustable manual legrest elevation, and a rectangular back. The contour of the seating system is ideal for a heavy duty user because it is critical to change the hip angle for proper support, as there is often a significant gap at the bottom of the back in the lumbar or thoracic area due to excess adipose tissue around the hips and buttocks, which causes significant reverse lean or low back discomfort. Opening the hip angle also alleviates discomfort and encourages better posture as adipose tissue in the stomach area and thighs interfere when in the seated position. Power recline has many other benefits:

 It provides passive range of motion, distributes pressure over the largest surface of the body, increases tolerance to staying in the wheelchair, and allows multiple functional

 positions.

Power recline improves trunk stability, postural stability, allows better trunk position to accommodate kyphosis, can decrease fatigue, increases respiratory capacity, and allows change of hip position for pain relief.

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009

Please choose a base option

TOP

Base Options

Anti-tippers

Anti-tippers are small diameter wheels mounted in front of the wheelchair base to improve forward stability and keep the wheelchair from tipping forward if it is in an unstable position.

Flat Free Inserts

Permobil’s flat free inserts are specialized gel-filled inner tubes that evenly fill the tube and offer a ride close to a pneumatic feel without the risk of the tire going flat. This could leave the wheelchair user stranded. The tires require no maintenance, which is critical as most wheelchair users cannot maintain adequate tire pressure for the best ride and balanced tracking.

Performance "S" Package

The performance "S" package is a high speed option for the C500 base. It includes high speed motors that allow the wheelchair speeds of 7.5 mph, 100 amp electronics, and an Enhanced

Steering Performance (ESP) module to improve tracking of the base so that higher speeds can be achieved without fishtailing. This higher performance is needed for the active user to have quicker responsiveness and speed across various terrains, through busy intersections, and for an active lifestyle.

Shroud w/ Light Package

The light package includes headlights, tail lights, and turn signals to make the wheelchair safe to use in low light conditions. It provides safety when used outdoors on the street, in a parking lot, crossing an intersection, or using public transportation. The cover (shroud) is specially molded to fit and protect the lights.

Batteries

The batteries are gel sealed, and two are necessary to power the wheelchair. They are maintenance free and are safe for travel on the road or in the air. Group 24 batteries are necessary to provide adequate power to the wheelchair due to add on power systems such as power tilt-in-space or recline and to increase the range of driving on a single charge.

P+PP1A Programmer

This programmer will allow the drive parameters of the controller to be modified to customize driving for optimal access. Parameters such as speed and acceleration in forward, reverse and turning can be changed, as well as the sensitivity and response of the joystick and power required to move. The programmer allows fine tuning to optimize driving and can be used to reprogram for changing needs.

Power Adjustable Seat Height

The power adjustable seat height allows vertical adjustment of the seat height by the wheelchair user. Elevation increases reach and allows more independence. It facilitates lateral transfers by allowing a level transfer or transfer from a higher to lower surface, which is gravity-assisted. It also facilitates forward transfer by allowing legs, hips to be more extended, thereby lessening the

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009 strain for the user to perform a stand-pivot transfer. Moving/driving while elevated allows better eye contact and allows better positioning for reaching, which can lead to independence in many activities, such as eating, cooking, and hand washing. Vertical rise has psychosocial benefit of eye-to eye contact, and further benefits the user by reducing neck strain. Medications can be kept out of reach of children but remain accessible.

Please select your additional features

TOP

Additional Features

ESP

ESP, or Enhanced Steering Performance, is a module containing a piezoelectric rotational sensor that is mounted inside of the front of the wheelchair chassis. This unit very quickly compares information to the signal coming from the input device and makes any adjustments to the motor output to keep the chair stable and traveling in the desired direction. Many factors, from uneven terrains, increased weight of powered seating functions, and ventilator trays, affect the tracking and balance of a power wheelchair. The ESP unit detects when the wheelchair deviates from the command given by the input device (joystick or other). It then gives the information to correct the deviation and return the travel to the desired direction. For wheelchairs driven with proportional controls, this allows the wheelchair to track straight at higher speeds and avoid fishtailing, which can be worse with the additional weight of a ventilator, tray, and auxiliary battery. For wheelchairs driven with switched, or non-proportional controls, this keeps the wheelchair driving in the desired direction. This is critical to the user that has to give many directional commands to veer or correct for deviations and can be extremely fatiguing to maintain switch contact and change commands when driving. The ESP unit reduces the need for most corrections, thereby causing less fatigue, frustration, and less worries about reliability and accuracy of hitting the desired switch and making much more efficient driving.

Front Wheel Drive

Front wheel drive has many unique benefits:

 Maneuverability - Front wheel drive wheelchairs have a very small turning radius.

 Intuitive driving - in contrast to rear wheel drive chairs, front wheel drive configurations are very intuitive to drive, especially for the first time driver. When turning around an obstacle (such as a corner), you pull up close to it as opposed to taking a wide swing

 around it.

Curb climbing - because the drive wheels are in the front, they pull the weight instead of pushing it. In combination with good traction on the drive wheels, it enables better curb or threshold climbing and negotiation of soft terrain, such as grass or gravel.

 Smooth drive - because of the obstacle climbing capabilities, the ride will be much smoother, which enhances CLIENT tolerance to driving. This provides prolonged sitting and driving tolerance". A smoother ride also reduces tone and helps reduce startle reflexes, thereby enhancing function.

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009

 Accommodation of knee flexion contractures - due to the lack of casters spinning on the front, knee flexion contractures and tight hamstrings can easily be accommodated without the need to raise the seat to floor height.

Suspension

This wheelchair comes standard with an improved shock absorbing system to decrease jolts and bumps when driven over uneven terrain such as grass or gravel. This will helps to maintain sitting balance and maintain contact with the controller to safely drive the wheelchair.

Suspension allows all four wheels to remain on the ground and also absorbs jolts from the terrain that can cause pain and increased pressure or shearing to the wheelchair user due to increased movement. The smoother driving is less likely to trigger abnormal reflexes or spasms, making sitting tolerance, posture, and driving better. This system will also decrease wear and tear on the wheelchair frame.

Please select your joystick & electronics

TOP

Joystick Options

Chin Cup

The chin cup allows better accessibility with a slight concave surface instead of a ball for driving.

Large Ball

A larger ball attachment for the joystick makes grasp and release easier for those who cannot easily hold or let go of the standard cone shape of the joystick.

Mushroom

The mushroom shape makes a standard joystick easier to drive for those using more gross motor movements to control the wheelchair. The large surface makes release easier and be positioned at the elbow, foot, or other location where control and access are preferred.

Soft Ball

This large, soft attachment for the joystick makes grasp easier with the entire palm and is easier to release to make the wheelchair stop. It can be accessed with more gross motor movements as well.

Stick

The stick provides a long vertical extension for those who can better grasp the joystick with the entire hand or hit it from the sides or back for directional control.

T-Handle

The T-handle allows more gross motor movements from the elbow and shoulder to control the joystick and facilitate turns.

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009

Joystick Mounting Options

Midline Joystick Mount

The midline mount allows the joystick to be placed at any point along the bar for midline mounting. This type of mounting is needed because the joystick is too difficult to reach

TOP

consistently or safely in its standard lateral position along the armrest. The mount swings out of the way for transfer.

Retractable

The retractable mount allows the joystick to be moved to the side and back for clearance without rotating. This makes it easier to drive up to tabletops and counters with the joystick pointing forward. It also can facilitate forward transfer by safely moving out to the side. The joystick can also be placed at any angle for better hand access.

Swing-Away

A swing away joystick mount allows the joystick to be swung in or out at any angle to allow closer access to tables and counters. It also can facilitate forward transfer by safely moving out to the side. The joystick can also be placed at any angle for better hand access.

Joystick Styles

Joystick Style Pilot + Series Joystick with 7 Buttons

The Pilot + Series Joystick is a proportional upgraded joystick that is separate from the controller box. The programmable electronics have separate drives and switch options available to safely meet different access, environmental, and terrain needs. The joystick is more compact and can be placed closer to the frame and may also be placed in multiple locations for better hand access.

This feature has the potential to make the overall profile of the wheelchair smaller for maneuvering. The seven buttons allow utilization of optional light package and also can “power" the chair sufficiently to activate power seat functions when the chair is turned off. When using multiple power options or alternative drive controls, this type of upgraded joystick is needed along with the expandable controller.

Pilot+ Joystick With M/J

The Pilot + Joystick with M/J is an upgraded proportional joystick with 1/8” mini-mono jacks and the joystick is separate from the controller box. The programmable electronics have separate drives and switch options available to safely meet different access, environmental, and terrain needs. The joystick is more compact and can be placed closer to the frame and may also be placed in multiple locations for better hand access. This feature has the potential to make the overall profile of the wheelchair smaller for maneuvering. Mono jack ports will allow specialty switches and controls to be used to operate the on/off and mode function. This is needed when the standard push or toggle buttons are not accessible due to lack of activation strength or limited active range of motion. When using multiple power options or alternative drive controls, this type of upgraded joystick is needed along with the expandable controller.

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009

Pilot+ Joystick With T/S

TOP

The Pilot + Joystick with T/S is an upgraded proportional joystick with toggle switches and the joystick is separate from the controller box. The programmable electronics have separate drives and switch options available to safely meet different access, environmental, and terrain needs.

The joystick is more compact and can be placed closer to the frame and may also be placed in multiple locations for better hand access. This feature has the potential to make the overall profile of the wheelchair smaller for maneuvering. Toggle switches facilitate access to the on/off and mode function. This is needed when the standard push buttons are not accessible due to lack of activation strength or limited active range of motion. When using multiple power options or alternative drive controls, this type of upgraded joystick is needed along with the expandable controller.

R-net Remote Joystick

The R-net Remote Joystick is a proportional upgraded joystick that is separate from the controller box. The programmable electronics have separate drives and switch options available to safely meet different access, environmental, and terrain needs. The LCD screen enables the users to view charge, speed, profiles, etc. R-net also provides for up to eight individually programmable profiles. Mono jack ports will allow specialty switches and controls to be used to operate the on/off and mode function. This is needed when the standard push or toggle buttons are not accessible due to lack of activation strength or limited active range of motion. When using multiple power options or alternative drive controls, this type of upgraded joystick is needed along with the expandable controller.

R-net Remote Joystick w/ Toggle Switches

The R-net Remote Joystick is a proportional upgraded joystick that is separate from the controller box. The programmable electronics have separate drives and switch options available to safely meet different access, environmental, and terrain needs. The LCD screen enables the users to view charge, speed, profiles, etc. R-net also provides for up to eight individually programmable profiles. Toggle switches facilitate access to the on/off and mode function. This is needed when the standard push buttons are not accessible due to lack of activation strength or limited active range of motion. When using multiple power options or alternative drive controls, this type of upgraded joystick is needed along with the expandable controller.

Compact Advanced Joystick for R-net

The Compact Advanced Joystick for R-net is a proportional upgraded joystick that is separate from the controller box. The programmable electronics have separate drives and switch options available to safely meet different access, environmental, and terrain needs. The joystick is more compact and can be placed closer to the frame and may also be placed in multiple locations for better hand access. The joystick may also be turned for optimal access to the buttons. This feature has the potential to make the overall profile of the wheelchair smaller for maneuvering.

When using multiple power options or alternative drive controls, this type of upgraded joystick is needed along with the expandable controller.

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009

Output Module (IOM) for R-net Control System

TOP

The Output Module (IOM) for R-net Control System is a device that allows a user to control an external device (ex: communication device, ECU, door opener, etc.) through the drive input

(Remote Joystick Module, head array, etc.). One output module is required for each separate external device to be controlled. Up to three output modules can be installed on one wheelchair.

Expandable Controller

The expandable controller is the power module located in the base of the chair that allows the input device to communicate with the drive motors and gear box. The expandable controller is needed for multiple power options on a base as a non-expandable controller (in the form of an integrated joystick and controller) will not accommodate these features. An expandable controller is used in conjunction with an upgraded joystick (Pilot + or R-net). An expandable controller is also required when any alternate drive controls are being used on a power wheelchair. With R-net, the expandable controller can accommodate up to six different types of drive inputs.

VSI Basic Joystick

The VSI Basic Joystick is an integral joystick and controller. The integral joystick means that there is not a separate power module/controller. This joystick has the capability of controlling one power function. A heavy duty cable connects the joystick to the other electronics, ensuring reliability and safety.

VR2 Basic Joystick

The VR2 Basic Joystick is an integral joystick and controller. The integral joystick means that there is not a separate power module/controller. This joystick has the capability of controlling one power function. A heavy duty cable connects the joystick to the other electronics, ensuring reliability and safety.

Please select any of the following that apply

TOP

Power Seat Functions

Power Recline

Power recline allows independent adjustment of back and hip angle and has multiple medical and functional benefits:

Partial or full powered recline opens hip angle

Provides passive range of motion

 Distributes pressure over largest surface of body

Increases sitting tolerance

 Allows multiple functional positions

Improves trunk stability, postural support

Alleviates orthostatic hypotension

 Allows supine transfers

Allows better trunk position to accommodate kyphosis

 Can decrease fatigue

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009

Can facilitate bladder emptying due to better catheter or urinal use

 Allows positioning for diapering without transfer

Increases respiratory capacity

 Allows change of hip position for pain relief

 May allow reduction of attendant/caregiver hours

Power Tilt

Power tilt allows independent orientation in space and has multiple medical and functional benefits:

 Provides powered orientation in space, 30 or 45 degrees

 Compensates for limited trunk stability

Allows independent orientation change

 Reduces shear along back and seat, especially when used in conjunction with recline

Maintains proper position in relation to AAC devices, computer

Allows for safer negotiation of inclines

 Improves respiration and digestion

Slows inevitable progression of neurologically based spinal deformity

 Provides some control of edema (best when used with elevating legrests)

 Inhibits triggering of abnormal tone or reflexes

Power Tilt and Recline

Power tilt and recline allow the optimal independent adjustment of back and hip angle and has multiple medical and functional benefits:

 Offers maximum pressure relief and postural support

 Offers the most functional positions for eating, self care, reaching, and repositioning

 Easiest for bowel/bladder management

 Recline alone can cause sliding forward and increase posterior pelvic tilt; the addition of

 tilt reduces shear when returning to neutral position from recline.

Best to address circulatory issues and blood pressure management

 Allows multiple changes in position for more comfortable sleeping

Best for increasing sitting tolerance and comfort

Most effective means of reducing edema with elevating legrests

Most effective means of reducing respiratory distress

 Facilitates therapy interventions

Provides most options for transfer for one or two assistants, or independently

 Allows for the most comfortable sleeping positions for some

 Tilting before reclining minimizes shearing along the trunk

Rotational Tilt

Rotational tilt is a combination powered system package with 15° lateral tilt, 120 ° recline, and

30° tilt and has many medical and functional benefits:

 Allows for postural drainage

 Reduces severe trunk and head lean by using gravity to assist with positioning

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009

Relieves pressure under the lateral aspects of pelvic bones (ischial tuberosities), which is a very common site of discomfort or skin breakdown, especially with pelvic obliquity and scoliosis of the spine.

The combination with standard power tilt and power recline offers large range of positioning options and allows CLIENT to maintain lateral tilt comfortably by leaning back and also allowing a stretch to the opposite side of the body for comfort and safety.

Seating System Options

TOP

Multiple Seat Function Control Kit

The Multiple Seat Function Control Kit describes the electronic components that allow the user to control two or more of the following actuators from a single interface (e.g., proportional joystick, touchpad, or non-proportional interface): power wheelchair drive, power tilt, power recline, power shear reduction, power leg elevation, power seat elevation, power standing. It includes a function selection switch which allows the user to select the motor that is being controlled and an indicator feature to visually show which function has been selected. This feature is contained both in a separate membrane switch box and integrated into the wheelchair drive interface.

Single Seat Function Control Kit

The Single Seat Function Control Kit is a power wheelchair accessory that identifies the electronic connection between wheelchair controller and interface to a power seat function. It is used when one power function is to be accessed through the drive control or a separate panel or switch.

Altswitch Alternating Seat Control

The Altswitch Alternating Seat Control provides 4 1/8" mono jacks to allow 4 momentary switches to control seat functions. This is needed because the standard control panel is inaccessible to CLIENT from all seat positions due to weakness, limited range or motion, or strength. A separate switch can be plugged in to access from any location along the body to toggle each power seat function up or down.

Seat Control Joyswitch

The Seat Control Joyswitch is a multi directional toggle that allows operation of up to 4 power seat functions through a single compact box instead of the standard seat control kit/panel. This is needed because the standard control panel is inaccessible to CLIENT from all seat positions due to weakness, limited range or motion, or strength.

Toggle Switch Kit for Seat Function Control Kit

The Toggle Switch Kit for Seat Function Control Kit provides an overlay for the seat control panel to use toggles instead of membrane to access power seat functions separately from the joystick.

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009

Heavy Duty Package

This package reinforces the wheelchair frame, which is necessary to accommodate the increased user weight. It increases the weight capacity of the wheelchair, making it sturdier and safer for prolonged use. It includes reinforced mounts for the standard power recline and for the armrests, a seat stabilizer, and anti-tippers.

Mount Seat Frame In Tall Position

The tall seat-to-floor height allows more options for lower leg adjustment and provides more ground clearance for those who have a longer lower leg length or otherwise need a higher seat.

Custom Seating Size Options

TOP

Custom Seat Depth

Custom seat depth is necessary to accommodate proper anatomical measurements as determined by upper leg length. Adequate seat depth is required to provide support to the pelvis and lower extremities and to properly disperse pressure under the sacrum, ischial tuberosities and thighs.

Custom Seat Width

Custom seat width is necessary to accommodate proper anatomical measurements. Adequate seat width is required to provide proper support to the pelvis and lower extremities and to prevent pressure sores from developing on the lateral aspects of the hips and thighs as they may press against the armrests.

Backrest Options

Curved Metal Back Support

The curved metal back support provides a surface onto which aftermarket backrests can be fastened.

Angle Adjustable Back Canes

The angle adjustable back canes allow back/hip angle adjustment from 85 to 115 degrees. This allows the hip angle to be set to a more comfortable position to accommodate hip contractures, provide better trunk or head stability, and increase respiratory capacity.

Ergo Back, Custom Sizes

The custom Ergo back is an ergonomic contoured backrest cut to specified height. It provides stability and comfort for unstable trunk position secondary to decreased trunk and upper extremity coordination and postural control. Standard back upholstery and linear seating orthoses are inadequate for postural support due to the need for contoured support for symmetrical positioning. With an orthotic back insert, the trunk is aligned and supported in a comfortable position. This support increases stability, safety, and potential for function in various situations, such as transport in a vehicle or on various terrains. The recommended orthosis simulates the contours of the trunk and provide stability for positioning and can reduce the risk of development of spinal deformities. The custom height will allow for optimal support to the appropriate

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009 position along the trunk and for proper placement of a headrest. The backrest is customizable upon ordering, and is further adjustable with the use of postural supports and in conjunction with seat functions.

Ergo Back, Standard Sizes

The Ergo back is an ergonomic contoured backrest, and is a component of the Corpus seating system. Aside from providing comfort, it accommodates unstable trunk position secondary to decreased trunk and upper extremity coordination and postural control. Standard back upholstery and linear seating orthoses are inadequate for postural support due to CLIENT’s need for contoured support to achieve symmetrical positioning. Using the provided adjustable lumbar and lateral supports, the trunk is aligned and sustained in a comfortable position. This support increases stability, safety, and potential for increased function in various situations, such as transport in a vehicle or on different environmental terrains. The recommended orthosis simulates the contours of the trunk and provide stability for positioning and can reduce the risk of developing spinal deformities. The backrest is customizable upon ordering, and is further adjustable with the use of postural supports and in conjunction with seat functions.

Rectangular Back

The rectangular backrest provides a flat back in 16" and 18" widths and range in height of 17-

29"from the seat pan. It is used in place of the standard Ergo back because its contours are not necessary to accommodate the needs of CLIENT. In this case, the built-in positioning of the

Ergo back is too aggressive and restricts the freedom of movement and comfort of CLIENT and the rectangular back promotes upright position and provides stability.

Solid Back

The solid back is a standard curved back in various customizable sizes. It promotes upright position and provides stability, and it has a standard curve to fit the trunk with better surface contact. It is critical for use with tilt, recline, or a headrest, and it reduces thoracic kyphosis and slouching.

Split Backrest

The Ergo backrest and back cushion are cut in two pieces, 8" from top. This can be used to allow a short back height for someone who “hooks" around the backrest or push handle with their arm for stability. It facilitates transfer from behind by making reach easier for the person lifting the trunk. It also can shorten the overall height for transport in a vehicle. It can be ideal for the individual who wants a full backrest when tilting and reclining, but also wants a shorter backrest for the purposes mentioned above.

Tubular Backrest Frame

The tubular backrest frame provides 1" diameter backrest tubes for mounting of aftermarket seating, as other manufacturers’ backrests may be more customized to CLIENT’s needs. The tubular backrest frame may be used with power tilt and manual recline capability.

Flat Backrest

The flat backrest is shaped to appropriately fit the back shell when standard lateral supports are omitted.

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009

Roho Backrest Cushion

TOP

The Roho Backrest Cushion fits into the selected Ergo Back shell in place of the standard cushion. It is made of ROHO’s Mid Profile cell flotation cushion, with air cells approximately 3” high at inflation. The Air-cell cushion is uniquely adjustable to the individual in that the nature of the device allows it to be custom configured or adjusted. Its vapor permeable cover allows for enhanced skin protection. The backrest shell matches the natural contours of the body while providing support and stability. It is customizable upon ordering, and further adjustable with additional supports and in conjunction with power seat functions.

An individual with postural instability would be an ideal candidate for this backrest, as the instability can be compensated for using additional supports and in conjunction with power seat functions. An individual with intact sensation will also benefit from the comfort of the ergonomic contour and the adjustability of the air-cell cushion. The vapor permeable cover is also a recommendation for an individual with a history of skin issues as it will encourage air flow.

Roho Backrest Cushion – Notched

The Roho Backrest Cushion fits into the selected Ergo Back shell in place of the standard cushion. It is made of ROHO’s Mid Profile cell flotation cushion, with air cells approximately 3” high at inflation. The Air-cell cushion is uniquely adjustable to the individual in that the nature of the device allows it to be custom configured or adjusted. Its vapor permeable cover allows for enhanced skin protection. The backrest shell matches the natural contours of the body while providing support and stability. It is customizable upon ordering, and further adjustable with additional supports and in conjunction with power seat functions.

An individual with postural instability would be an ideal candidate for this backrest, as the instability can be compensated for using additional supports and in conjunction with power seat functions. An individual with intact sensation will also benefit from the comfort of the ergonomic contour and the adjustability of the air-cell cushion. The vapor permeable cover is also a recommendation for an individual with a history of skin issues as it will encourage air flow. Notches are cut on the side to accommodate lateral supports.

Notch Backrest

The standard Ergo backrest cushion can be ordered notched to accommodate lateral supports.

Seat Cushion Options

Ergo Seat Cushion

The Ergo seat cushion is made from various densities of foam and has a removable, easily washable upholstered cover. It provides contours to match the normal anatomic contours of the pelvis to enhance stability, positioning, and comfort.

Miniflex Seat Cushion

The Miniflex seat cushion provides a comfortable seating surface for pediatric chair users.

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009

Armrest Options

TOP

Height Adjustable Armrests

Height adjustable armrests are necessary to create proper support for the shoulder, elbows and trunk. The adjustable height feature allows for placement of the armrest pads at a height that does not elevate the shoulders and creates trunk support. It also allows a tray to be set at the proper height for optimal function. Height adjustable armrests can facilitate transfer and weight shift and allows repositioning. Seat cushions can raise seat height significantly, and armrests that are too low may cause slouching of the shoulders, head and trunk.

2" Armrest Height Extensions

The extension allows armrests to be raised an additional 2" or accommodates thicker cushions or longer trunk-to-arm measurements by allowing the entire body of the armrest to shift forward while maintaining an appropriate height. It also allows higher support for arm troughs or trays needed for function and support.

Arm Trough Adaptors

Arm trough adaptors, available in 1" and 7/8" diameters, allow mounting of aftermarket armpads and troughs to the standard Corpus armrest hardware when the standard Corpus armrests do not meet the needs of CLIENT.

Armrest Pouch

The armrest pouch is an essentials bag that hangs under armpad to carry medications, supplies, keys, or other items necessary for daily living.

Armrest Support, Inner

The inner support is a pad that attaches to inside edge of the Corpus armrest for elbow/forearm support to keep it positioned safely and comfortably on the armrest. This is critical due to weakness, loss of range of motion, or inability to maintain position on the armrest, which can affect access to driving controls.

Armrest Support, Outer

The outer support is a pad that attaches to outside edge of the Corpus armrest for elbow/forearm support to keep it positioned safely and comfortably on the armrest. This is critical due to weakness, loss of range of motion, or inability to maintain position on the armrest, which can affect access to driving controls

Armrest Supports, HD

The HD support provides a reinforced bracket mounted at angle under armrest, which strengthens the armrest and allows for safer push off for weight shift. It still allows the armrest to flip back for lateral access.

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009

Legrest Options

TOP

3" Width Between Two-Piece Footplates

The wider 3" spacing further separates the Corpus footplates to better align lower legs for those with wider hips or more abduction at the knees. The extra space also allows for closer access to a table by aligning the footplates to straddle a post under the table, thereby making eating or reaching easier.

70 Degree Swing-Away Legrests (For PS)

Swing-away legrests can be moved out of the way or be removed completely for safe transfer.

They support each lower leg separately and can make it easier for an individual to perform a lateral transfer to a bed, chair, or toilet.

Aeron Legrest Assembly (For PS)

The Aeron Legrest Assembly provides a means for manual legrest elevation, and is mounted in the center.

Calf Supports

The calf supports are angle and height adjustable pads that attach to the legrests. These padded calf supports are necessary to support the lower legs when the leg is elevated, or to keep feet from tucking under and getting stuck behind footplates when in the neutral seated position. Calf supports are especially important when using a tilt-in-space power seating system. The padding relieves pressure by providing an additional surface to distribute pressure, and has a mild contour to fit the lower leg.

Legrest Assembly, One-Piece Footplate

The one-piece footplate is an option for standard Corpus legrests for those with a foot deformity or danger of getting foot caught between individual footplates. It is also stronger with a one-point attachment.

Legrest Extension Kit

The extension kit allows for a lower legrest adjustment from 16 – 21" from the seat pan. This is needed to accommodate for a longer lower leg length so that the feet are supported as the upper leg is fully resting on the cushion and distributing weight. Without this, an individual with a long lower leg length would find their knees lifted at the front edge of the cushion, causing discomfort and increased pressure on the ischial tuberosities.

Multi-Axis Adjustable Footplates (For PS)

These footplates allow angle adjustment in several planes: flexion/extension, inversion/eversion, and rotation. Multi-axis adjustable footplates are necessary to accommodate foot deformities as they can be positioned for plantarflexion or dorsiflexion deformity, and for inversion or eversion of the foot. These footplates completely support the foot, which evenly distributes pressure to provide relief along the foot and provide stability.

Power Articulating Elevating Legrest

Power articulating elevating legrests allow legrest elevation and articulation, which maintains leg

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009 extension while elevating. They improve circulation and reduce or prevent edema. They maintain stretch and range of motion for short range and can accommodate for range of motion deficits.

Power elevating legrests provide change of position due to pain or neuropathy and can facilitate better bowel/bladder management. They can increase clearance to navigate thresholds and slopes by raising up. The powered feature also allows legrests be tucked back more than normal to shorten wheelbase for maneuverability.

Power Leg Length

The power leg length feature allows a 4" vertical adjustment of the footplate in relation to the seat. This facilitates transfer by allowing the footplate to reach the floor for those who cannot clear their legs or step around the footplate. It also provides relief to feet by lowering them to alleviate pressure. Raising the footplate is useful for better floor clearance when driving over obstacles or ramps, and can provide comfort to hips and knees by increasing or decreasing flexion.

Stand and Drive Option For Combi Stander Seat

The stand and drive assembly will allow the Combi stander to be driven while in a standing position as it includes additional electronics necessary to allow the wheelchair to be driven positioning this configuration, and an additional set of wheels that are attached beneath the footplates, supporting them and allowing them to roll across the floor as it is driven in a standing position. Driving while standing has multiple benefits: it allows better access and reach, interaction with peers, and it provides the low magnitude, high frequency forces associated with dynamic standing, which have been shown to reduce osteoporosis and decrease spasms.

Please select any of the following that apply

Accessories

TOP

Bodypoint Padded Hip Belt

The padded hip belt provides safety, and its additional comfort will make it more likely to be used.

Positioning Belt, Retractable

A pelvic positioning belt is necessary to maintain proper pelvic position in relation to the back of the seat. It is placed across the pelvis to ensure proper pelvic orientation within the seating system and to provide safety. This style has a button which will allow the pelvic belt to retract like a car seat belt to keep straps from falling to the side, getting caught under the seat or tires, and will stay within reach of CLIENT for independent fastening.

Positioning Belt, Long

A pelvic positioning belt is necessary to maintain proper pelvic position in relation to the back of the seat. It is placed across the pelvis to ensure proper pelvic orientation within the seating system and to provide safety. This style has a button which will allow the pelvic belt to retract

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009 like a car seat belt to keep straps from falling to the side, getting caught under the seat or tires, and will stay within reach of CLIENT for independent fastening.

Headrest, Adjustable/Removable

A contoured adjustable angle headrest is medically necessary to provide posterior and lateral support to the cervical spine and head. This headrest is used for positioning and head control and comes with the necessary hardware to mount the headrest pad to the wheelchair backrest.

Headrest, Removable Hardware

Adjustable hardware is required so that the headrest is properly placed to provide optimal support to CLIENT’s head and cervical spine. This headrest is also removable for ease of transfers in and out of the wheelchair and to reduce the wheelchair’s overall height when traveling.

Universal Headrest Adaptor

This adaptor bracket provides a universal pre-drilled hole pattern for more secure and reinforced mounting of an aftermarket headrest from other manufacturers.

Uni-Track Support and Hardware

The Uni-track system accommodates an infinite amount of adjustments and placement points using few modular pieces that are customizable to the individual. The support surfaces are used for trunk support, thigh support, calf support, or amputee support, and can be interchangeable.

The accompanying hardware mounts to the seating system using a track and consists of multidirectional joints, thereby making attachment and subsequent adjustment limitless.

Lateral Supports, Standard

Thoracic lateral supports are curved, removable, height adjustable trunk supports that attach to the shell of the Ergo back, mounted on removable hardware for ease of transfers. These are necessary to provide lateral support to the trunk and spine, which will promote midline positioning and prevent falling or leaning to either side. They provide aggressive support and limit uncontrolled movements of a weak trunk, enabling CLIENT to sit in a functional upright position. They also assist in reducing or preventing further spinal deformity.

Lateral Supports, Swing-Away

Thoracic lateral supports are curved, removable, height adjustable trunk supports for the Ergo back. These are necessary to provide lateral support to the trunk and spine, which will promote midline positioning and prevent falling or leaning to either side. They are needed to support and limit a weak trunk by providing aggressive support to sit in a functional upright position. They also assist in reducing or preventing spinal deformity and are mounted on removable, swingaway hardware for ease of transfers.

Thigh Supports, Short or Long

Thigh or hip supports are multi-position, angle adjustable pads on removable hardware. These pads can be placed at the hips or anywhere along the length of the thigh to align the legs due to high or low tone or windswept deformity, or to prevent excessive abduction and external rotation of the hips, which can contribute to hip dislocation.

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009

Chest Bar

The chest bar provides an additional safety precaution, particularly necessary when standing.

Abductor Kit

A medial thigh support (abductor) is necessary to maintain the pelvis and upper legs in a prescribed amount of abduction, or to prevent adduction of the hips, which may result in hip dislocation. It is removable for ease of transfer.

Knee Block Assembly

The knee block assembly is a set of removable anterior knee block pads, which are necessary to properly position the pelvis. They are positioned anterior to the patella and tibia to prevent pelvic rotation. This helps to prevent the development of pelvic and spinal deformation. Anterior knee blocks are also used as a block to prevent posterior pelvic tilt and sliding forward out of the wheelchair seat. This feature comes standard on a standing wheelchair, and is necessary to keep the knees straight to avoid sliding out of the system.

Transfer Handles

Transfer handles are removable handles that can be placed in multiple positions in their removable and height adjustable brackets, which are mounted to the side of the seat frame. They provide a support near the front edge of the seat to facilitate transfer in or out of the wheelchair and for weight shifting.

Push Handles

Push handles are two handles mounted to the backrest frame to facilitate pushing of the wheelchair when the wheelchair user is unable to move the wheelchair independently. They can be used to hang essential items from the back. For some, with a lower backrest, the push handles can provide a place to hook the elbow to provide stability and promote safe forward or lateral reach.

Back Pack Clips, Carabiner Style

This hardware is bolted onto the solid back support and will be used to hold a bag to carry essential items. The clips lock to keep the bag from falling off of the back.

Essential Carrier

The essential carrier is a bag attached to rear swing arm for carrying important items such as medications, supplies, keys, or other things necessary for daily living.

Upper Extremity Support

A wheelchair tray table is necessary to assist in upper trunk positioning and upper extremity support. It also provides a horizontal surface for working or eating, or to facilitate carrying of essential items. The necessary hardware to mount the tray to the wheelchair frame is angle adjustable for better visual access to the items on the tray, and is removable for transfer.

Upper Extremity Support Joystick Cutout

A wheelchair tray table is necessary to assist in upper trunk positioning and upper extremity

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009 support. It also provides a horizontal work surface. A custom cutout for the wheelchair tray will be required for access to the joystick so CLIENT can drive the wheelchair with the tray in place.

The necessary hardware to mount the tray to the wheelchair frame is angle adjustable for better visual access to the items on the tray, and is removable for transfer.

Oxygen Holder

An oxygen holder can accommodate an oxygen cylinder while driving the wheelchair.

Please select any of the following that apply

TOP

Alternative Drive Systems

Gimble Joystick w/ Armrest Mount

The Gimble Joystick is a compact proportional joystick that does not have a separate display with switches; therefore it is easy to mount at any angle. The Gimble Joystick must be used with a specialty control interface such as an Omni or Input Module (IOM). This type of joystick is small for optimal armrest mounting.

Gimble Joystick w/ Midline Mount

The Gimble Joystick is a compact proportional joystick that does not have a separate display with switches; therefore it is easy to mount at any angle. The Gimble Joystick must be used with a specialty control interface such as an Omni or Input Module (IOM). Instead of the standard armrest mount, the midline mounting hardware allows for the compact joystick to be mounted in the most accessible place, which can be at the hand or near the mouth.

Gimble Joystick w/ Swing Away Chin Boom

The Gimble Joystick is a compact proportional joystick that does not have a separate display with switches; therefore it is easy to mount at any angle. The Gimble Joystick must be used with a specialty control interface such as an Omni or Input Module (IOM). The swing away chin mount includes midline mounting hardware mounted to the back of the wheelchair and compact joystick. This system allows the user to have the same capability for driving a proportional control around their mouth. This joystick also allows good access around the mouth or chin and is quite durable. The swing away chin boom allows for the joystick to be moved for ease of transfers.

Gimble Joystick w/ Haims Harness Small

The Gimble Joystick is a compact proportional joystick that does not have a separate display with switches; therefore it is easy to mount at any angle. The Gimble Joystick must be used with a specialty control interface such as an Omni or Input Module (IOM). The Haims Harness system (small – for neck width up to 5”) allows the joystick to stay with CLIENT around the neck and chest for driving with the mouth or chin. This joystick also allows good access around the mouth or chin and is quite durable.

Gimble Joystick w/ Haims Harness - Large

The Gimble Joystick is a compact proportional joystick that does not have a separate display with switches; therefore it is easy to mount at any angle. The Gimble Joystick must be used with

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009 a specialty control interface such as an Omni or Input Module (IOM). The Haims Harness system (large – for neck width up to 7”) allows the joystick to stay with CLIENT around the neck and chest for driving with the mouth or chin. This joystick also allows good access around the mouth or chin and is quite durable.

Gimble Joystick w/ Power Swing Away Chin Boom

The Gimble Joystick is a compact proportional joystick that does not have a separate display with switches; therefore it is easy to mount at any angle. The Gimble Joystick must be used with a specialty control interface such as an Omni or Input Module (IOM). The swing away chin mount includes powered swing away midline mounting hardware mounted to the back of the wheelchair and compact joystick. This system allows CLIENT to have the same capability for driving a proportional control around their mouth, as their medical condition prevents them from using either hand for driving. This joystick also allows good access around the mouth or chin and is quite durable. The powered swing away hardware allows the user to push a button to make the joystick swing out of the way for transfer, or to remove it during peer interactions, eating, etc.

Gimble Joystick w/ Armrest Mount

The Gimble Joystick is a compact proportional joystick that does not have a separate display with switches; therefore it is easy to mount at any angle. The Gimble Joystick must be used with a specialty control interface such as an Omni or Input Module (IOM). This type of joystick is small for optimal armrest mounting.

Gimble Joystick w/ Midline Mount

The Gimble Joystick is a compact proportional joystick that does not have a separate display with switches; therefore it is easy to mount at any angle. The Gimble Joystick must be used with a specialty control interface such as an Omni or Input Module (IOM). Instead of the standard armrest mount, the midline mounting hardware allows for the compact joystick to be mounted in the most accessible place, which can be at the hand or near the mouth.

Gimble Joystick w/ Swing Away Chin Boom

The Gimble Joystick is a compact proportional joystick that does not have a separate display with switches; therefore it is easy to mount at any angle. The Gimble Joystick must be used with a specialty control interface such as an Omni or Input Module (IOM). The swing away chin mount includes midline mounting hardware mounted to the back of the wheelchair and compact joystick. This system allows the user to have the same capability for driving a proportional control around their mouth. This joystick also allows good access around the mouth or chin and is quite durable. The swing away chin boom allows for the joystick to be moved for ease of transfers.

Gimble Joystick w/ Haims Harness Small

The Gimble Joystick is a compact proportional joystick that does not have a separate display with switches; therefore it is easy to mount at any angle. The Gimble Joystick must be used with a specialty control interface such as an Omni or Input Module (IOM). The Haims Harness system (small – for neck width up to 5”) allows the joystick to stay with CLIENT around the neck and chest for driving with the mouth or chin. This joystick also allows good access around the mouth or chin and is quite durable.

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009

Gimble Joystick w/ Haims Harness - Large

The Gimble Joystick is a compact proportional joystick that does not have a separate display with switches; therefore it is easy to mount at any angle. The Gimble Joystick must be used with a specialty control interface such as an Omni or Input Module (IOM). The Haims Harness system (large – for neck width up to 7”) allows the joystick to stay with CLIENT around the neck and chest for driving with the mouth or chin. This joystick also allows good access around the mouth or chin and is quite durable.

Gimble Joystick w/ Power Swing Away Chin Boom

The Gimble Joystick is a compact proportional joystick that does not have a separate display with switches; therefore it is easy to mount at any angle. The Gimble Joystick must be used with a specialty control interface such as an Omni or Input Module (IOM). The swing away chin mount includes powered swing away midline mounting hardware mounted to the back of the wheelchair and compact joystick. This system allows CLIENT to have the same capability for driving a proportional control around their mouth, as their medical condition prevents them from using either hand for driving. This joystick also allows good access around the mouth or chin and is quite durable. The powered swing away hardware allows the user to push a button to make the joystick swing out of the way for transfer, or to remove it during peer interactions, eating, etc.

Mini Joystick w/ Powered Swing Away Chin Boom

The swing away chin mount includes powered swing away midline mounting hardware mounted to the back of the wheelchair and a light touch mini proportional joystick. This system allows the user to have the same capability for driving a proportional control around their mouth, as their medical condition prevents them from using either hand for driving. The mini proportional joystick requires »1mm of excursion and <10grams of force to activate, making it possible to still keep proportional control for a user who does not have the strength or range of motion to activate another joystick. The powered swing away hardware allows the user to push a button to make the joystick swing out of the way for transfer, or to remove it during peer interactions, eating, etc.

The Mini Joystick must be used with a specialty control interface such as an Omni or Input

Module (IOM).

Mini Joystick w/ Swing Away Boom

The swing away chin boom includes midline mounting hardware mounted to the back of the wheelchair and a light touch mini proportional joystick. This system allows the CLIENT to have the same capability for driving a proportional control around their mouth, as their medical condition prevents them from using either hand for driving. The mini proportional joystick requires »1mm of excursion and <10grams of force to activate, making it possible to still keep proportional control for a user who does not have the strength or range of motion to activate another joystick. The hardware allows the bracket to swing out of the way for transfer. The Mini

Joystick must be used with a specialty control interface such as an Omni or Input Module (IOM).

Mini Joystick w/ Haims Harness System

The mini proportional joystick with the Haims harness system allows the joystick to stay with

CLIENT around the neck and chest for driving with the mouth or chin. This system allows a more compact, very light touch proportional control to be mounted for use when a standard

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009 joystick is not feasible for driving. The mini proportional joystick requires »1mm of excursion and <10grams of force to activate, making it possible to still keep proportional control for a user who does not have the strength or range of motion to activate another joystick. This joystick can be mounted at a finger, chin, or lip, depending on where control is best. The Mini Joystick must be used with a specialty control interface such as an Omni or Input Module (IOM).

Mini Joystick w/ Armrest Mount

The mini proportional joystick with adjustable mounting hardware allows a more compact, very light touch proportional control to be mounted for use when a standard joystick is not feasible for driving. The mini proportional joystick requires »1mm of excursion and <10grams of force to activate, making it possible to still keep proportional control for a user who does not have the strength or range of motion to activate another joystick. This joystick can be mounted at a finger, chin, or lip, depending on where control is best. The Mini Joystick must be used with a specialty control interface such as an Omni or Input Module (IOM).

Mini Joystick w/ Midline Mount

The mini proportional joystick with midline mounting hardware allows for access more midline instead of the standard armrest mount. This system allows a more compact, very light touch proportional control to be mounted for use when a standard joystick is not feasible for driving.

The mini proportional joystick requires »1mm of excursion and <10grams of force to activate, making it possible to still keep proportional control for a user who does not have the strength or range of motion to activate another joystick. This joystick can be mounted at a finger, chin, or lip, depending on where control is best. The Mini Joystick must be used with a specialty control interface such as an Omni or Input Module (IOM).

Tablet Control Pad

The Tablet Control Pad is a unique proportional drive input which allows CLIENT to control a power wheelchair in a very similar manner to a mouse being controlled by a touchpad on a laptop computer. Each time CLIENT touches the surface, the neutral point resets itself. The

Tablet Control allows clients with fluctuating tone to establish neutral anywhere on the tablet surface avoiding the need to consistently access the same location (required for switches and joysticks).

Head Array Adult 5 Switch HDR-A5

The Head Array Adult 5 Switch HDR-A5 is a specialty controller is a specialty controller that allows the wheelchair to move forward, turning, reversing, or stopping the wheelchair by moving the head toward the proper pad, with each direction being controlled through a switch embedded in the headrest pad that are activated when in close proximity to the switch without requiring contact. It is necessary because CLIENT lacks the upper extremity function needed to drive a power wheelchair with a standard joystick. The Head Array must be used with a specialty control interface such as an Omni.

Head Array – Adult 3 Switch HDR-A4

The Head Array Adult 3 Switch HDR-A5 is a specialty controller is a specialty controller that allows the wheelchair to move forward, turning, reversing, or stopping the wheelchair by moving the head toward the proper pad, with each direction being controlled through a switch embedded

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009 in the headrest pad that are activated when in close proximity to the switch without requiring contact. It is necessary because CLIENT lacks the upper extremity function needed to drive a power wheelchair with a standard joystick. The Head Array must be used with a specialty control interface such as an Omni.

Sip & Puff System

The Sip and Puff System allows breath control, using a variety of hard and soft sips and puffs from the mouth to control the different driving directions. This type of input device is needed because CLIENT lacks the upper extremity function needed to drive the wheelchair with a standard joystick. The Sip & Puff must be used with a specialty control interface such as an

Omni.

Sip & Puff System w/ Fiber Optic Opti-Stop

The Sip and Puff System with Fiber Optic Opti-Stop allows breath control, using a variety of hard and soft sips and puffs from the mouth to control the different driving directions. The fiber optic switch detects when the mouth is “visible" and the chair is safe to drive, and it acts as an emergency stop if the control is not in proper position. The Sip & Puff must be used with a specialty control interface such as an Omni.

Omni Plus Control Module System

The Omni is a specialty control interface and display for the electronics. It is a controller that allows multiple alternate driving controls used at the head, mouth, chin, foot, etc. to interface to the wheelchair electronics. It also interprets commands and allows programming to optimize driving and to provide access to other functions on the power wheelchair, including power seat functions, lights, and environmental controls as needed.

Input Module (IOM) for R-net Control System

The Input Module (IOM) is a specialty control interface for the R-net electronics. This device allows a proportional or switched drive input to be connected to an R-net Control System without the use of an Omni.

Please select any of the following that apply:

TOP

Alt Drive Accessories

Microlite Switch

The Microlite Switch is a small, very light touch mechanical switch with 1/8" mono jack plug. It is used as a select or reset switch to either turn the wheelchair on or off, or to change modes or reset to access other functional integrated into the power wheelchair.

Buddy Button

The Buddy Button is a medium size mechanical, colorful switch with moderate pressure to activate. It is used as a select or reset switch to either turn the wheelchair on or off, or to change modes or reset to access other functional integrated into the power wheelchair.

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009

Mini Cup Switch

The Mini Cup Switch is a small mechanical switch with moderate pressure to activate. It is used as a select or reset switch to either turn the wheelchair on or off, or to change modes or reset to access other functional integrated into the power wheelchair.

Proximity Switch

The Proximity switch is a zero touch switch that is activated when coming within _"of the switch. It is used as a select or reset switch to either turn the wheelchair on or off, or to change modes or reset to access other functional integrated into the power wheelchair.

Mini Joystick 5 Switch OC

The 5-Switch Mini Joystick is non-proportional joystick that has 5 switch closures in the different driving directions: forward, reverse, left, and right, and the fifth closure is achieved by pushing down on the joystick. This allows for directional control from a small joystick for those with good range of motion within a small area but does not have sufficient control to control the excursion of a joystick for proportional driving (like a gas pedal). It is used most often at the mouth or chin.

Wafer Board With 5 Switches

This board made by TASH is an array with 5 membrane switches for directional input and a reset or select switch. It holds all 5 switches in a pre-formed arrangement, with one switch to control each direction, and holding down two switches for veering.

Dual Control Switch Box

The Dual Control Switch Box allows two input devices to be plugged in at same time, with a toggle to change between driving controls. This is needed when switching between two different driving methods by CLIENT or can be used so that an attendant can drive the wheelchair from behind with a joystick.

Auxiliary Control Module

The Auxiliary Control Module allows other devices like communication or environmental control devices to be integrated through the Omni Plus interface. Then, the driving method, whether switches or joystick used for driving the wheelchair can also, through a menu, be used to control other devices needed for communication, computer access, or environmental controls.

Chin Control Unit Stand Alone

The Chin Control Unit includes a swing away mount off the backrest. It is a remote joystick that can be mounted at the chin for proportional driving, and it has two adjustable raised buttons to access on/off and mode switches so that all control of the wheelchair can be accessed around the chin or mouth.

Attendant Controls

Co-Pilot Attendant Control

This attendant control has a handle with built-in power sensors to assist the caregiver in pushing

Letter of Medical Necessity Justification for Permobil Power Chairs

Revised 3/17/2009 the wheelchair from behind. It is necessary to allow others to drive the power wheelchair due to fatigue, unsafe conditions like an outdoor intersection, steep ramp, or very tight turn. It can be used to maneuver the chair into position for better transfer. The combined weight of CLIENT and the power wheelchair make it difficult for anyone to push the wheelchair in these situations.

P+ DAC Attendant Control

This attendant control is a joystick style controller to allow caregivers to steer/drive chair from behind. It is necessary to allow others to drive the power wheelchair due to fatigue, unsafe conditions like an outdoor intersection, steep ramp, or very tight turn. It can be used to maneuver the chair into position for better transfer. The combined weight of CLIENT and the power wheelchair make it difficult for anyone to push the wheelchair without powered assistance in these situations.

END

TOP

THIS IS A TEMPORARY WIP DOCUMENT. THE NEW BUILD YOUR LMN TOOL WILL

SOON BE POSTED ON THE US WEBSITE.

For questions, comments or additions to this document please email: tara.gentile@permobilus.com

or Stephanie.waddell@permobilus.com

Download