Prescription for Rehabilitation and
Certification of Medical Necessity

Patient's Name Date of Birth
Address City
State Zip
Date of Service Diagnosis Code
Procedure Elite Seat
       

Description and Reason Elite Seat Prescribed:  The elite seat® is a low-load prolonged stretch (LLPS) device. It allows resisted active / passive motion within a restricted - projected range. The elite seat® sustains a set level of tension using a patient conterolled low load progressive stretch using a ratcheted internal cabling system that is patient controlled and prescribed to correct the loss of knee extension, increase range of motion, decrease knee pain and improve overall function.

Deemed Medically Necessary:   

  1. As an adjunct to physical therapy for obtaining full knee extension after a knee injury, during the pre-operative or post-operative period of time in patients with symptoms of persistent knee stiffness, or contracture and whose affected knee is not symmetric with the unaffected knee.
  2. In the post operative period for patients with limitd ROM and poses a meaningful functional limitation, as judged by the prescribing physician.
  3. For patients unable to benefit from standard physical therapy modalities due to the inability to straighten the affected knee/leg.
  4. In the actue post-operative period for patients who have undergone additional surgery to improve ROM of previously affected joint for up to 4 months and if the patient improvement can be demonstrated.
  5. For patients unable to benefit from standard physical therapy modalities due to the inabilitiy to excercise resulting from limited function due to lack of extension and pain.

Recommended Protocol: 
The elite seat® is to be used 3-5 times a day for 10 minutes  / session while in a  supine position to allow for maximum extension.

Physician Name Address
City State
Zip Phone Number - - -
Fax Number - - - NPI #  
Estimated Length of Prescription Date Prescribed

I, the undersigned, certify that the following prescribed equipment is medically necessary.  The equipment is bi-lateral reasonable and necessary in reference to accepted standards of medical practice in the treatment of this patient’s condition.

 

Date of Surgery Type of Sugery
Date Elite Seat Used Hospital Name
Date Discharged from Hospital HCPCS Code
       
       

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