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 |
