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 proven contracture treatment device specifically prescribed to correct any loss of motion in the knee joint, which is the established protocol in the first line of treatment in the rehabilitation of the knee when a flexion contracture is present. The elite seat® is a medically necessary modality for the patient in the rehabilitation process.

Deemed Medically Necessary:   

  1. The Elite Seat is used 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.
  6. In the Orthopedic aftercare or other orthopedic indications.

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, the Elite Seat®, is a proven Contracture Treatment Device for the knee and is medically necessary. The Elite Seat® is both reasonable and necessary in reference to accepted standards of medical practice in the treatment of the patient's condition and therefore, NO SUBSTITUTIONS ALLOWED.


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

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