Medical Policy Content

Policy ID: E-36-023

Section: Durable Medical Equipment (DME)

Effective Date: September 15, 2025

Applies To: Commercial, Medicaid Expansion, and Metallic

Description

Speech generating devices (SGDs) are speech aids that provide individuals with severe speech impairment the ability to meet their functional speaking needs. SGDs provide digitized speech as well as synthesized speech. However, SGDs do not include external speech processors that are part of a cochlear device/system used to capture and amplify sound.

Policy Application

All claims submitted under this policy’s section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date; and/or

All claims submitted under this policy’s section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

SGDs may be considered medically necessary when ordered by the treating physician and ALL of the following criteria are met:

A formal evaluation of the individual's cognitive and communication abilities has been performed by a Speech Language Pathologist (SLP). The findings of this evaluation must be documented as a formal written evaluation and forwarded to the individual's treating physician prior to the device being ordered. The written evaluation must include ALL of the following elements:
- Current communication impairment, including the type, severity, language skills, cognitive ability, and anticipated course of the impairment; and
- An assessment of whether the individual's daily communication needs could be met using other natural modes of communication; and
- A description of the functional communication goals expected to be achieved and treatment options; and
- Rationale for selection of a specific device and any accessories; and
- Demonstration that the individual possesses the cognitive and physical abilities to effectively use the selected device and any accessories to communicate; and
- A treatment plan that includes a training schedule for the selected device; and
- For a subsequent upgrade to a previously issued SGD, information regarding the functional benefit to the individual of the upgrade compared to the initially provided SGD; and
The individual's medical condition is one resulting in a severe expressive speech impairment; and
The individual's speaking needs cannot be met using natural communication methods; and
Other forms of treatment have been considered and ruled out; and
The device ordered will meet the individual's current communication needs; and
The device ordered will meet the individual's anticipated communication needs, or the device can be modified as necessary to meet the individual's anticipated needs.

Accessories may be considered medically necessary if the coverage criteria for the base device are met and the medical necessity for each accessory is clearly documented in the formal written evaluation by the SLP. Speech pathology services pertaining to the individual's evaluation and training in use of these devices may also be considered medically necessary.

SGD's not meeting the criteria as indicated in this policy is/are considered not medically necessary. When the SGD is not covered, accessories are also not covered.

Requests for more than one SGD will be denied as not medically necessary.

Laptop computers, desktop computers, tablet computers, personal digital assistants (PDAs) or other devices that are not dedicated SGDs are not covered because they do not meet the definition of durable medical equipment (DME). This is a benefit denial.

Communication aids that are not speech generating devices (e.g., communication boards) do not meet the definition of DME. Therefore, they are benefit denials. In addition, services related to non-speech generating devices are also not covered.

Related Components and Accessories for SGDs

Speech generating software programs enabling a laptop computer, desktop computer, tablet computer, or PDA to function as an SGD may be considered medically necessary as a SGD within the terms of this policy.

Procedure Codes

92605

92606

92607

92608

92609

92618

E1902

E2500

E2502

E2504

E2506

E2508

E2510

E2511

E2512

E2513

E2599

V5336

Eye gaze or eye glance technology

Eye gaze or eye glance technology (e.g., DynaVox EyeMax System) may be considered medically necessary when the following criteria are met:

Individual is unable to control or sustain fine/gross body movements
Individual must have direct vision in one or both eyes
Individual should have the ability to look up, down, left and right.
Individual must have adequate vision to view the screen
Individual must have the ability to focus on one spot for a brief period of time.
Provider must submit medical records and/or additional documentation to determine coverage for eye gaze access devices.

Eye gaze or eye glance technology not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Code

E2599

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

CURRENT CODING

CPT

92605

Evaluation and prescription of nonspeech-generating and alternative communication device, first hour

Commercial

92606

Therapy service for use of nonspeech-generating device with programming

Commercial

92607

Evaluation with prescription of speech-generating and alternative communication device, first hour

Commercial

92608

Evaluation with prescription of speech-generating and alternative communication device, each additional 30 minutes

Commercial

92609

Therapy service for use of speech-generating device with programming

Commercial

92618

Evaluation and prescription of nonspeech-generating and alternative communication device, each additional 30 minutes

Commercial

E1902

Communication board, non-electronic augmentative or alternative communication device

Commercial

E2500

Speech generating device, digitized speech, using pre-recorded messages, less than or equal to 8 minutes recording time

Commercial

E2502

Speech generating device, digitized speech, using pre-recorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time

Commercial

E2504

Speech generating device, digitized speech, using pre-recorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time

Commercial

E2506

Speech generating device, digitized speech, using pre-recorded messages, greater than 40 minutes recording time

Commercial

E2508

Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device

Commercial

E2510

Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access

Commercial

E2511

Speech generating software program, for personal computer or personal digital assistant

Commercial

E2512

Accessory for speech generating device, mounting system

Commercial

E2513

Accessory for speech generating device, electromyographic sensor

Commercial

E2599

Accessory for speech generating device, not otherwise classified

Commercial

V5336

Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid)

Commercial

92605

Evaluation and prescription of nonspeech-generating and alternative communication device, first hour

Metallic

92606

Therapy service for use of nonspeech-generating device with programming

Metallic

92607

Evaluation with prescription of speech-generating and alternative communication device, first hour

Metallic

92608

Evaluation with prescription of speech-generating and alternative communication device, each additional 30 minutes

Metallic

92609

Therapy service for use of speech-generating device with programming

Metallic

92618

Evaluation and prescription of nonspeech-generating and alternative communication device, each additional 30 minutes

Metallic

E1902

Communication board, non-electronic augmentative or alternative communication device

Metallic

E2500

Speech generating device, digitized speech, using pre-recorded messages, less than or equal to 8 minutes recording time

Metallic

E2502

Speech generating device, digitized speech, using pre-recorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time

Metallic

E2504

Speech generating device, digitized speech, using pre-recorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time

Metallic

E2506

Speech generating device, digitized speech, using pre-recorded messages, greater than 40 minutes recording time

Metallic

E2508

Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device

Metallic

E2510

Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access

Metallic

E2511

Speech generating software program, for personal computer or personal digital assistant

Metallic

E2512

Accessory for speech generating device, mounting system

Metallic

E2513

Accessory for speech generating device, electromyographic sensor

Metallic

E2599

Accessory for speech generating device, not otherwise classified

Metallic

V5336

Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid)

Metallic

92605

Evaluation and prescription of nonspeech-generating and alternative communication device, first hour

Medicaid Expansion

92606

Therapy service for use of nonspeech-generating device with programming

Medicaid Expansion

92607

Evaluation with prescription of speech-generating and alternative communication device, first hour

Medicaid Expansion

92608

Evaluation with prescription of speech-generating and alternative communication device, each additional 30 minutes

Medicaid Expansion

92609

Therapy service for use of speech-generating device with programming

Medicaid Expansion

92618

Evaluation and prescription of nonspeech-generating and alternative communication device, each additional 30 minutes

Medicaid Expansion

E1902

Communication board, non-electronic augmentative or alternative communication device

Medicaid Expansion

E2500

Speech generating device, digitized speech, using pre-recorded messages, less than or equal to 8 minutes recording time

Medicaid Expansion

E2502

Speech generating device, digitized speech, using pre-recorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time

Medicaid Expansion

E2504

Speech generating device, digitized speech, using pre-recorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time

Medicaid Expansion

E2506

Speech generating device, digitized speech, using pre-recorded messages, greater than 40 minutes recording time

Medicaid Expansion

E2508

Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device

Medicaid Expansion

E2510

Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access

Medicaid Expansion

E2511

Speech generating software program, for personal computer or personal digital assistant

Medicaid Expansion

E2512

Accessory for speech generating device, mounting system

Medicaid Expansion

E2513

Accessory for speech generating device, electromyographic sensor

Medicaid Expansion

E2599

Accessory for speech generating device, not otherwise classified

Medicaid Expansion

V5336

Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid)

Medicaid Expansion

References

Stern S, Chobany C, Beam A, et al. Use of speech generating devices can improve perception of qualifications for skilled, verbal and interactive jobs. Work. 2017; 56(2):199-211.
Theiman-Bourque K, Feldmiller S, Hoffman L, Johner S. Incorporating a peer- mediated approach into speech-generating device intervention: effects on communication of preschoolers with autism spectrum disorder. J Speech. 2018;61:2045–2061.
Mclay L, Schafer C, van der Meer L, et al. Acquisition, preference and follow- up comparison across three AAC modalities taught to two children with autism spectrum disorder. Intl J Disabil Dev Educ. 2017;64(2):117-130.
O’Neill T, Light J, Pope L. Effects of interventions that include aided augmentative and alternative communication input on the communication of individuals with complex communication needs: A meta-analysis. J Speech Lang Hear Res. 2018;61(7):1743-1765.
Ripat J, Verdonck M, Gacek C, McNikol S. A qualitative metasynthesis of the meaning of speech-generating devices for people with complex communication needs. Augmentation and Alternative Communication. 2019;35(2):69-79.
Gevarter C, Horan K, Sigafoos J. Teaching preschoolers with autism to use different speech-generating device display formats during play: Intervention and secondary factors. Lang Speech Hear Serv Sch. 2020;51:821-835.
Bourque K, Goldstein H. Expanding communication modalities and functions for preschoolers with autism spectrum disorder: secondary analysis of a peer partner speech-generating device intervention. J Speech Lang Hear Res. 2020;63:190-205.
Roman A, Baylor C, Johnson L, Barton M. Expanding availability of speech generating device evaluation and treatment to people with amyotrophic lateral sclerosis (pALS) through telepractice: Perspectives of pALS and communication partners. Am J Speech Lang 2021;30:2098-2114.
Carnett A, Hansen S, Tullis C, Machalicek W. Using behavioral skills training via telehealth to increase teachers use of communication interventions and increase student use of speech-generating devices in a high school functional skills classroom. J Intellect Disabil Res. 2021;65(12):133-148.
Chavers T, Morris M, Schlosser R, Koul R. Effects of a systematic augmentative and alternative communication intervention using a speech- generating device on multistep requesting and generic small talk for children with severe autism spectrum disorder. Am J Speech Lang 2021;30:2476-2491.

ND Committee Review

Internal Medical Policy Committee 5-19-2020 Revision - Effective July 06, 2020

Updated Language

Internal Medical Policy Committee 5-20-2021 Coding update Effective July 05, 2021

Removed procedure code E2515

Internal Medical Policy Committee 3-23-2022 Revision with Coding update - Effective May 02, 2022

Added additional criteria; and
Added procedure codes E2512; and V5336.

Internal Medical Policy Committee 3-23-2023 Annual Review - Effective May 01, 2023

no changes in criteria

Internal Medical Policy Committee 5-14-2024 Annual Review - Effective July 01, 2024

no changes in criteria; and
Added Policy Application

Internal Medical Policy Committee 9-17-2024 Coding Update- Effective October 01, 2024

Added procedure code E2513

Internal Medical Policy Committee 5-13-2025 Revision - Effective July 07, 2025

Changed section of policy from paragraph form to bullets.

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: E-36-024

Section: Durable Medical Equipment (DME)

Effective Date: July 01, 2026

Applies To: Commercial, Medicaid Expansion, and Metallic

Description

Speech generating devices (SGDs) are speech aids that provide individuals with severe speech impairment with the ability to meet their functional speaking needs. SGDs provide digitized speech as well as synthesized speech. However, SGDs do not include external speech processors that are part of a cochlear device/system used to capture and amplify sound.

Policy Application

All claims submitted under this policy’s section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

SGDs may be considered medically necessary when ordered by the treating physician and ALL of the following criteria are met:

A formal evaluation of the individual's cognitive and communication abilities has been performed by a Speech Language Pathologist (SLP). The findings of this evaluation must be documented as a formal written evaluation and forwarded to the individual's treating physician prior to the device being ordered. The written evaluation must include ALL of the following elements:
- Current communication impairment, including the type, severity, language skills, cognitive ability, and anticipated course of the impairment; and
- An assessment of whether the individual's daily communication needs could be met using other natural modes of communication; and
- A description of the functional communication goals expected to be achieved and treatment options; and
- Rationale for selection of a specific device and any accessories; and
- Demonstration that the individual possesses the cognitive and physical abilities to effectively use the selected device and any accessories to communicate; and
- A treatment plan that includes a training schedule for the selected device; and
- For a subsequent upgrade to a previously issued SGD, information regarding the functional benefit to the individual of the upgrade compared to the initially provided SGD; and
The individual's medical condition is one resulting in a severe expressive speech impairment; and
The individual's speaking needs cannot be met using natural communication methods; and
Other forms of treatment have been considered and ruled out; and
The device ordered will meet the individual's current communication needs; and
The device ordered will meet the individual's anticipated communication needs, or the device can be modified as necessary to meet the individual's anticipated needs.

SGD's not meeting the criteria as indicated in this policy is/are considered not medically necessary. When the SGD is not covered, accessories are also not covered.

Requests for more than one SGD will be denied as not medically necessary.

Related Components and Accessories for SGDs

Procedure Codes

92605

92606

92607

92608

92609

92618

E1902

E2500

E2502

E2504

E2506

E2508

E2510

E2511

E2512

E2513

E2599

V5336

Eye gaze or Eye Glance Technology Criteria

Eye gaze or eye glance technology (e.g., DynaVox EyeMax System) may be considered medically necessary when ALL of the following criteria are met:

Individual is unable to control or sustain fine/gross body movement; and
Individual must have direct vision in one or both eyes; and
Individual should have the ability to look up, down, left and right; and
Individual must have adequate vision to view the screen; and
Individual must have the ability to focus on one spot for a brief period of time; and
Provider must submit medical records and/or additional documentation to determine coverage for eye gaze access devices.

Eye gaze or eye glance technology not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Code

E2599

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

The American Academy of Pediatrics Clinical Report 2025

Children with communication disabilities can benefit considerably from AAC, as AAC can help maximize their developmental potential.

CURRENT CODING

CPT

92605

Evaluation and prescription of nonspeech-generating and alternative communication device, first hour

Commercial

92606

Therapy service for use of nonspeech-generating device with programming

Commercial

92607

Evaluation with prescription of speech-generating and alternative communication device, first hour

Commercial

92608

Evaluation with prescription of speech-generating and alternative communication device, each additional 30 minutes

Commercial

92609

Therapy service for use of speech-generating device with programming

Commercial

92618

Evaluation and prescription of nonspeech-generating and alternative communication device, each additional 30 minutes

Commercial

E1902

Communication board, non-electronic augmentative or alternative communication device

Commercial

E2500

Speech generating device, digitized speech, using pre-recorded messages, less than or equal to 8 minutes recording time

Commercial

E2502

Speech generating device, digitized speech, using pre-recorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time

Commercial

E2504

Speech generating device, digitized speech, using pre-recorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time

Commercial

E2506

Speech generating device, digitized speech, using pre-recorded messages, greater than 40 minutes recording time

Commercial

E2508

Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device

Commercial

E2510

Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access

Commercial

E2511

Speech generating software program, for personal computer or personal digital assistant

Commercial

E2512

Accessory for speech generating device, mounting system

Commercial

E2513

Accessory for speech generating device, electromyographic sensor

Commercial

E2599

Accessory for speech generating device, not otherwise classified

Commercial

V5336

Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid)

Commercial

92605

Evaluation and prescription of nonspeech-generating and alternative communication device, first hour

Metallic

92606

Therapy service for use of nonspeech-generating device with programming

Metallic

92607

Evaluation with prescription of speech-generating and alternative communication device, first hour

Metallic

92608

Evaluation with prescription of speech-generating and alternative communication device, each additional 30 minutes

Metallic

92609

Therapy service for use of speech-generating device with programming

Metallic

92618

Evaluation and prescription of nonspeech-generating and alternative communication device, each additional 30 minutes

Metallic

E1902

Communication board, non-electronic augmentative or alternative communication device

Metallic

E2500

Speech generating device, digitized speech, using pre-recorded messages, less than or equal to 8 minutes recording time

Metallic

E2502

Speech generating device, digitized speech, using pre-recorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time

Metallic

E2504

Speech generating device, digitized speech, using pre-recorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time

Metallic

E2506

Speech generating device, digitized speech, using pre-recorded messages, greater than 40 minutes recording time

Metallic

E2508

Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device

Metallic

E2510

Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access

Metallic

E2511

Speech generating software program, for personal computer or personal digital assistant

Metallic

E2512

Accessory for speech generating device, mounting system

Metallic

E2513

Accessory for speech generating device, electromyographic sensor

Metallic

E2599

Accessory for speech generating device, not otherwise classified

Metallic

V5336

Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid)

Metallic

92605

Evaluation and prescription of nonspeech-generating and alternative communication device, first hour

Medicaid Expansion

92606

Therapy service for use of nonspeech-generating device with programming

Medicaid Expansion

92607

Evaluation with prescription of speech-generating and alternative communication device, first hour

Medicaid Expansion

92608

Evaluation with prescription of speech-generating and alternative communication device, each additional 30 minutes

Medicaid Expansion

92609

Therapy service for use of speech-generating device with programming

Medicaid Expansion

92618

Evaluation and prescription of nonspeech-generating and alternative communication device, each additional 30 minutes

Medicaid Expansion

E1902

Communication board, non-electronic augmentative or alternative communication device

Medicaid Expansion

E2500

Speech generating device, digitized speech, using pre-recorded messages, less than or equal to 8 minutes recording time

Medicaid Expansion

E2502

Speech generating device, digitized speech, using pre-recorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time

Medicaid Expansion

E2504

Speech generating device, digitized speech, using pre-recorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time

Medicaid Expansion

E2506

Speech generating device, digitized speech, using pre-recorded messages, greater than 40 minutes recording time

Medicaid Expansion

E2508

Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device

Medicaid Expansion

E2510

Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access

Medicaid Expansion

E2511

Speech generating software program, for personal computer or personal digital assistant

Medicaid Expansion

E2512

Accessory for speech generating device, mounting system

Medicaid Expansion

E2513

Accessory for speech generating device, electromyographic sensor

Medicaid Expansion

E2599

Accessory for speech generating device, not otherwise classified

Medicaid Expansion

V5336

Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid)

Medicaid Expansion

References

Roman A, Baylor C, Johnson L, Barton M. Expanding availability of speech generating device evaluation and treatment to people with amyotrophic lateral sclerosis (pALS) through telepractice: Perspectives of pALS and communication partners. Am J Speech Lang 2021;30:2098-2114.
Carnett A, Hansen S, Tullis C, Machalicek W. Using behavioral skills training via telehealth to increase teachers use of communication interventions and increase student use of speech-generating devices in a high school functional skills classroom. J Intellect Disabil Res. 2021;65(12):133-148.
Chavers T, Morris M, Schlosser R, Koul R. Effects of a systematic augmentative and alternative communication intervention using a speech- generating device on multistep requesting and generic small talk for children with severe autism spectrum disorder. Am J Speech Lang 2021;30:2476-2491.
Sterrett K, Holbrook A, Landa R, Kaiser A, Kasari C. The effect of responsiveness to speech-generating device input on spoken language in children with autism spectrum disorder who are minimally verbal†. Augment Altern Commun. 2023;39(1):23-32.
Bekteshi S, Konings M, Karlsson P, Criekinge TV, Dan B, Monbaliu E. Teleintervention for users of augmentative and alternative communication devices: A systematic review. Dev Med Child Neurol. 2023;65(2):171-184.
Edgar T, Schlosser R, Koul R. Effects of an augmentative and alternative communication intervention package on socio-communicative behaviors between minimally speaking autistic children and their peers. AJSLP. 2024;33(6):1619-1638.:
Leonet O, Orcasitas-Vicandi M, Langarika-Rocafort A, Mondragon NI, Etxebarrieta GR. A systematic review of augmentative and alternative communication interventions for children aged from 0 to 6 years. Lang Speech Hear Serv Sch. 2022 Jul 6;53(3):894-920.

ND Committee Review

Internal Medical Policy Committee 5-19-2020 Revision - Effective July 06, 2020

Updated Language

Internal Medical Policy Committee 5-20-2021 Coding update Effective July 05, 2021

Removed procedure code E2515

Internal Medical Policy Committee 3-23-2022 Revision with Coding update - Effective May 02, 2022

Added additional criteria; and
Added procedure codes E2512; and V5336.

Internal Medical Policy Committee 3-23-2023 Annual Review - Effective May 01, 2023

no changes in criteria

Internal Medical Policy Committee 5-14-2024 Annual Review - Effective July 01, 2024

no changes in criteria; and
Added Policy Application

Internal Medical Policy Committee 9-17-2024 Coding Update- Effective October 01, 2024

Added procedure code E2513

Internal Medical Policy Committee 5-13-2025 Revision - Effective July 07, 2025

Changed section of policy from paragraph form to bullets.

Internal Medical Policy Committee 4-14-2026 Annual Review-Effective July 01, 2026

Updated References
Updated Description
Updated Professional Statement

Disclaimer

Policy ID: E-36-022

Section: Durable Medical Equipment

Effective Date: July 01, 2018

Revised Date: September 25, 2024

Revision Effective Date: October 01, 2024

Last Reviewed: September 17, 2024

Archived Date: July 06, 2025

Applies To: Commercial and Medicaid Expansion

Description

Policy Application

For Date of Processing (DOP): All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

For Date of Service (DOS): All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

*See below to determine whether the policy rules apply to initial and adjustment claims based on date of processing (DOP) or Date of Service (DOS).

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

SGDs may be considered medically necessary when ordered by the treating physician and ALL of the following criteria are met:

A formal evaluation of the individual's cognitive and communication abilities has been performed by a Speech Language Pathologist (SLP). The findings of this evaluation must be documented as a formal written evaluation and forwarded to the individual's treating physician prior to the device being ordered. The written evaluation must include ALL of the following elements:
- Current communication impairment, including the type, severity, language skills, cognitive ability, and anticipated course of the impairment; and
- An assessment of whether the individual's daily communication needs could be met using other natural modes of communication; and
- A description of the functional communication goals expected to be achieved and treatment options; and
- Rationale for selection of a specific device and any accessories; and
- Demonstration that the individual possesses the cognitive and physical abilities to effectively use the selected device and any accessories to communicate; and
- A treatment plan that includes a training schedule for the selected device; and
- For a subsequent upgrade to a previously issued SGD, information regarding the functional benefit to the individual of the upgrade compared to the initially provided SGD; and
The individual's medical condition is one resulting in a severe expressive speech impairment; and
The individual's speaking needs cannot be met using natural communication methods; and
Other forms of treatment have been considered and ruled out; and
The device ordered will meet the individual's current communication needs; and
The device ordered will meet the individual's anticipated communication needs, or the device can be modified as necessary to meet the individual's anticipated needs.

SGD's not meeting the criteria as indicated in this policy is/are considered not medically necessary. When the SGD is not covered, accessories are also not covered.

Requests for more than one SGD will be denied as not medically necessary.

Related Components and Accessories for SGDs

Procedure Codes

92605

92606

92607

92608

92609

92618

E1902

E2500

E2502

E2504

E2506

E2508

E2510

E2511

E2512

E2513

E2599

V5336

Eye gaze or eye glance technology

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Eye gaze or eye glance technology (e.g., DynaVox EyeMax System) may be considered medically necessary for an individual who meets the requirements for a SGD as documented on this policy but has limited use of his or her extremities that renders the individual unable to control or sustain fine/gross body movements that would enable him or her to access an SGD using more conventional access methods such as switches or direct touch. The individual must have direct vision in one or both eyes, and for full control over the system, should have the ability to look up, down, left and right. The individual must also have adequate vision to view the screen and must have the ability to focus on one spot for a brief period of time.

Contraindications include, but may not be limited to, those individuals with the following conditions: continuous, uncontrolled head movement; nystagmus. It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage for eye gaze access devices.

Eye gaze or eye glance technology not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Code

E2599

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

Rationale

Not Applicable

ND Committee Review

Internal Medical Policy Committee 5-19-2020 Language update.

Internal Medical Policy Committee 5-20-2021 Coding update

Removed procedure code E2515

Internal Medical Policy Committee 3-23-2022 Revision with Coding update- Effective May 02, 2022

Added additional criteria; and
Added procedure codes E2512; and V5336.

Internal Medical Policy Committee 3-23-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 5-14-2024 Annual Review-no changes in criteria

Added Policy Application

Internal Medical Policy Committee 9-17-2024 Coding Update- Effective October 01, 2024

Added procedure code E2513

Medical Policy Search

Medical Policy Content

Policy Application

Procedure Code

Policy Application

Description

Policy Application

Criteria

Related Components and Accessories for SGDs

Procedure Codes

Eye gaze or eye glance technology

Procedure Code

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

Rationale

ND Committee Review

Links

Disclaimer