Checklist for Strollers
Name, DOB, Demographic info including height and weight
Primary diagnosis and related diagnoses, prognosis
Medical history:
Make sure to describe complex diagnoses, include spinal abnormalities.
Functional mobility:
What is the child’s strength and ROM?
How does tone, spasticity, paraplegia, contractures, etc. effect the child’s ability to maintain upright standing and walking?
Primary means of mobility, ability to transfer, sit, stand, ambulate and assistance required. What is their balance in sitting and standing?
What other equipment does the child have and was it purchased by insurance?
How much assistance does this child require for ADL’s?
Current situation and why it is not working:
What mobility device is the child using currently?
Examples: A standard stroller (XXX has outgrown this stroller, no longer appropriate, does not provide the proper seating and positioning support this child requires). “Child needs to be carried after walking for 20 minutes, child is too heavy to be carried and is not safe for caregiver or child.” “Child needs to take a seated rest break after walking for 20 minutes and it takes at least 5 minutes to recover.” “Child is unable to demonstrate a safe walking pace while crossing busy streets going to medical appointments and is dangerous.” “Child is impulsive, requires constant supervision and is unsafe in busy parking lots or parking garages where the child is not easily seen.”
Trial period of equipment:
It always looks good to have successfully trialed a piece of equipment that you are requesting; however, for strollers it is not necessary. (Unless insurance requests documentation of a successful trial)
What other less costly alternatives have been considered but ruled out:
Here you can say the child ambulates with crutches or posterior walker again but XXX does not demonstrate a safe gait speed using these devices.
If you are requesting a stroller other than the Trotter stroller, you must explain why the Trotter is not appropriate as it is the least costly alternative. Examples:
The Trotter stroller was considered but ruled out as XXX hip width measures only 9 inches and the smallest Trotter stroller is 12 inches and is too big for XXX at this time.
We are requesting an activity base and stroller; a Trotter stroller does not have the option to be used on an activity base within the home.
The Trotter was considered and ruled out due to the seat to back angle causing this child to sit down in the stroller.
XXX requires more upright positioning, needs to be able to sit forward and requires additional supported that the Trotter can’t provide (Trekker or Hoggi Bingo).
Here you also need to state that the stroller you chose is a less costly alternative to a lite weight manual wheelchair in which is not appropriate for the child at this time. Examples:
XXX cannot self-propel a wheelchair therefore a standard WC would not increase independence (also state that a tilt in space wheelchair is not appropriate).
XXX does not have any spinal abnormalities and is not at risk for scoliosis therefore a wheelchair with additional supports is not indicated at this time.
XXX does not have a history and is not at risk for skin integrity issues therefore, a specialized cushion or tilt and recline features are not indicated at this time.
XXX is able to ambulate within the community but demonstrates safety concerns in busy environments and is impulsive requiring contact supervision.
What are you requesting and describe why you need all added accessories:
Specific name of stroller, size and all accessories. Examples:
Headrest extension: “required to provide adequate support to her cervical spine in a reclined position and will provide appropriate support as the child grows in height.”
Transit option: “ this is required so the stroller can be used to transport the child on the school bus or with medical transport if necessary.”
Harness: “this is required to provide added support to XXX while seated in this device and during transportation. This will keep the child safely secured anteriorly and will keep the child from acting impulsively.”
Calf panel: “this item is required to provide appropriate support to the LE’s during transportation. XXX is moving constantly and will kick his/her legs while in sitting. The calf panel will provide protection to his/her lower extremities to avoid self-injury and bruising.”
Under Seat Storage Basket: “this item is necessary to provide additional storage for necessary items (medications and supplies) that will be required during a possible emergent situation. This added storage will allow for additional space so XXX’s parents can safely push the stroller and have access to essential items when they are needed.” (List medical supplies if you can, oxygen, suction, etc.)
CANOPY: If you are requesting a canopy, please make sure to include the following information in your justification. If this is not justified correctly, insurance will request additional information and make it very hard to get this accessory!!!
Include in justification and restate this info: Does the child have a medical condition such as cardiopulmonary issues, GI issues that cause dehydration, febrile seizures, etc. that are exacerbated when exposed to the sun or overheated? Is the child taking medications that have photosensitivity side effects? List out other less costly alternatives such as, protective clothing and hats, staying out of direct sun light, spray bottle, portable fan, ice packs and cold towels to keep cool… EXAMPLE: “This item is required as it has functional applications that can help mitigate health complications caused from environmental stressors. This feature will provide added protection from direct sunlight in which causes XXX to be uncomfortable, irritable and impulsive. With XXX’s complex medical history, it is important to avoid any potential health complications whenever possible. XXX is taking medications that have photosensitivity side effects. Other less costly alternatives have been used to keep XXX out of the sunlight such as staying out of the direct sun, which is not always possible depending on the time of day and direction of travel, clothing with sun protection has been used but causes XXX to overheat, cold packs and wet towel cause XXX to get wet and more irritable and difficult to keep frozen and cold when traveling, spray bottles have been trialed but again this method causes clothing to be wet.”