MEDICAL POLICY

POLICY
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POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Augmentative and Alternative Communication Devices/Speech Generating Devices

Number 1.01.502*

Effective Date March 25, 2014

Revision Date(s) 03/10/14; 05/13/13; 02/11/13; 03/13/12; 03/08/11; 03/09/10; 06/09/09; 03/11/08; 10/9/07; 12/12/06; 11/11/05; 12/14/04; 01/01/04; 11/11/03; 12/10/02; 10/06/98; 10/30/97

Replaces N/A

*Medicare has a policy

Policy

Augmentative and alternative communication (AAC) devices and speech generating devices (SGDs) may be considered medically necessary durable medical equipment (DME) in the treatment of the functional disability caused by a speech or communication impairment when ALL criteria are met. See the Policy Guidelines.

AAC devices and SGDs are considered not medically necessary DME when criteria are not met. See Policy Guidelines.

Note: Artificial larynx devices are not addressed in this policy. (See note in Policy Guidelines and Benefit Application.)

Related Policies

1.01.518

Stuttering Treatment Devices

8.03.505

Speech Therapy

Policy Guidelines

Prior to the delivery of an AAC device/SGD ALL of the following criteria must be met:

  1. The patient’s cognitive and communication abilities are assessed by an independent speech-language pathologist (SLP) (who is not working for the ACD/SGD supplier).
  2. The written SLP evaluation must include ALL of the following information:
  1. Current communication impairment, including the type, severity, language skills, cognitive ability, and anticipated course of the impairment; and
  2. An assessment of whether the individual’s daily communication needs could be met using other natural (oral/sign) means of communication; and
  3. A description of the functional communication goals expected to be achieved and treatment options; and
  4. Rationale for selection of a specific device and any accessories; and
  5. Demonstration that the patient has a speech-therapy treatment plan that includes training for the selected device; and
  6. Cognitive and physical abilities to effectively use the selected device and any accessories to communicate; and
  7. If an upgraded ACC device/SGD is needed, documentation states the functional benefit to the patient, compared to the initially provided device; and
  1. The patient’s medical condition is one resulting in a severe expressive speech impairment; and
  2. The patient’s speaking needs cannot be met using natural (oral/sign) communication methods; and
  3. Other forms of treatment have been considered and ruled out; and
  4. The patient’s speech impairment is likely to benefit from the recommended device.

The patient record should contain documentation that the licensed speech therapist’s written evaluation and recommendation were sent to the treating or referring clinician prior to ordering the AAC device/SGD.

The device recommended is expected to be useful and functional without major repair for at least five years. Replacement or upgrading to new equipment would not be covered unless the person’s physical ability to use their current equipment changes significantly.

Coverage for supportive training such as speech therapy in combination with learning to use the device depends on the member’s contract benefits.

When the medical necessity of a SGD device has been established, the least costly device that is appropriate and effective will be allowed for coverage.

Installation of the software program for a dedicated SGD and/or technical support for a dedicated SGD is not separately reimbursable.

Non-covered Hardware/Devices

Multiple-function hardware devices that do not meet the definition of durable medical equipment (DME) include but are not limited to:

  • Desktop and laptop computers,
  • Personal digital assistants (PDA),
  • Smartphones,
  • Tablets

The listed hardware/devices are not primarily medical in nature, perform multiple functions and are not specifically designed as dedicated AAC devices/SGDs. These devices can be used for functions other than speech generation by someone without severe speech impairment. The listed hardware and devices do not meet the definition of durable medical equipment (DME)

Covered Speech-generating Software

Software that enables a desktop computer, laptop computer, PDA, smartphone, tablet or other multiple-function hardware devices to function as an SGD is covered as an SGD.

Installation of the software program and/or technical support is not separately reimbursable.

Definition of Terms

Durable Medical Equipment (DME)

DME consists of items that are:

  • Primarily and normally used to serve a medical purpose
  • Not useful to a person without an illness or injury
  • Ordered or prescribed by a physician
  • Reusable
  • Long-lasting and can stand repeated use
  • Appropriate for and primarily used in the home setting*
  • Not implantable in the body

*Exception: depending on where speech augmentation is needed, the AAC/SGD may be used in the home, school, work and/or community setting(s) when other criteria are met.

NOTE: Laryngeal devices are not addressed in this policy. Patients who have undergone a total laryngectomy may have coverage for a medically necessary laryngeal device, indwelling or electronic speech aide, under a prosthetic benefit. Examples of devices include handheld artificial larynx (electrolarynx), indwelling trachoesophageal (TE) voice prosthesis, and a device that consists of an oral unit attached to a denture or retainer and a controller that transmits radio waves to an amplifier like the UltraVoiceTM device (UltraVoice, New Town Square, PA).

Description

Augmentative and alternative communication (AAC) devices are more commonly known as speech generating devices (SGD). These devices are durable medical equipment used solely as speech aides for patients who are unable to speak or have a functional disability caused by severe speech impairment. Specially designed function-specific devices that generate synthesized speech based on user input, can assist the patient who cannot communicate by speaking or by using alternatives, such as writing and sign language. Communication of medical needs allows the patient to maintain or improve his or her health.

The pathophysiology of the speech disorder may involve spasticity, flaccidity, tremor, rigidity, ataxia or other motor impairments. These motor impairments may affect motor control throughout the body, limiting the patient’s ability to use other means of communication (e.g. writing notes, using sign language) or manipulating a low-tech communication system.

High technology augmentative communication devices are electronic and are usually computer based. They are dedicated devices that convert the patient’s selections (of letters, words, symbols and/or phrases) into electronically produced speech. These devices vary in method of access with direct selection, or indirect selection by visual and/or auditory scanning and use of a switch or joy-stick. Many different devices, with varying capabilities, are available.

Scope

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This policy does not apply to Medicare Advantage.

Benefit Application

Contractual or benefit limitations on durable medical equipment or equipment upgrades may be applicable. Benefit or contract language describing the "least costly alternative" may also be applicable.

Low technology, non-electronic augmentative communication devices are not addressed by this policy.

Artificial larynx devices or electronic speech aides used by patients who have undergone a total laryngectomy are considered prosthetics. These devices are not addressed in this policy, but may be considered medically necessary under a prosthetic benefit.

Rationale

This policy was initially developed in 1997and has been updated on a regular basis using MEDLINE literature searches. The most recent literature search was conducted through January 2014. Following is a summary of the key literature.

Millar et al. reported in 2006 on a meta-analysis of literature published between 1975 and 2003 showed that “AAC [augmentative and alternative communication] offers significant benefits for individuals with developmental disabilities in terms of enhancing communicative competence and promoting language development. Ninety-four percent of the participants in the reviewed studies demonstrated increased speech production during or following at least one of the AAC interventions investigated.” (1) However, all of the studies had very small sample sizes and were not specific to a particular developmental characteristic. None of the studies had the primary goal of determining the impact of AAC on speech development.

Wilkinson & Hennig in 2007 published a research review that states practitioners and researchers recognize the critical importance of evidence-based practice in AAC assessment and intervention, and clear recommendations have emerged for critical analysis of evidence. However, they also state despite the appreciation of its importance, the actual base of evidence itself is still at its inception and conclude more evidence based research is needed to evaluate ACC interventions.(2)

Beukelman et al. in 2007 reported on a systematic review of the state of the science of augmentative and alternative communication (AAC) devices for adults with acquired neurogenic conditions/communication disorders. The authors summarized the advances, acceptance, use and limitations in AAC devices for 6 groups of people; those with amyotrophic lateral sclerosis (ALS), traumatic brain injury (TBI), brainstem impairment, severe/chronic aphasia and apraxia of speech, primary progressive aphasia (PPA), and dementia. The authors state that the impact of AAC services and technology is inconsistent across the various groups of individuals. Acceptance of AAC interventions and use have increased for individuals with amyotrophic lateral sclerosis (ALS) and traumatic brain injury (TBI), with more studies and documentation available than a decade ago. AAC options for formerly underserved populations (aphasia, brainstem impairment, and dementia) are steadily improving, though not yet a standard of practice. Several underserved groups of individuals with neurologic conditions such as Parkinson’s disease, Huntington’s disease, multiple sclerosis, and myasthenia gravis might benefit from AAC interventions; however, a literature review over the past decade revealed little systematic activity for these groups and further research is needed. (3)

Rispoli et al. in 2010 reported on a systematic review that identified 35 studies with a total of 86 participants with developmental disabilities. The review examined the following features for the studies: (a) participant characteristics, (b) SGD function, (c) SGD characteristics, (d) intervention procedures, (e) intervention results and (f) certainty of evidence. There were 17 different devices included in the studies. Positive outcomes (e.g., target communication skills improved for all participants) were reported in 86% (n= 30) of studies. Fifty-four percent of the positive studies were categorized as providing conclusive evidence. Mixed outcomes (e.g., some participants improved and others did not improve target communication skills) were reported in 14% (n= 5) of studies. The authors concluded the data from articles was "promising due to the large number of conclusive studies and the replication of intervention approaches." (4)

Medicare National Coverage

Speech generating devices are covered under the Durable Medical Equipment (DME) benefit. In order for a beneficiary's DME to be eligible for reimbursement, the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.

Laptop computers, desktop computers, personal digital assistants (PDAs) or other devices that are not dedicated speech generating devices (SGDs) are not covered because they do not meet the definition of DME.

Software that enables a laptop computer, desktop computer or PDA to function as an SGD is covered as an SGD; however, installation of the program or technical support are not separately reimbursable.

Upgrades to speech generating devices and/or software programs that are provided within the 5 year useful lifetime of the device are noncovered. (5-6)

References

  1. Millar DC, Light, JC, Schlosser RW. The Impact of Augmentative and Alternative Communication Intervention on the Speech Production of Individuals with Development Disabilities: A Research Review. Journal of Speech, Language and Hearing Research. 2006; 49; 248-264.
  2. Wilkinson KM, Hennig S. The State of Research and Practice in Augmentative and Alternative Communication for Children with Developmental/Intellectual Disabilities. MRDD Research Reviews 2007; 13:58-69.
  3. Beukelman DR, Fager S, et al. AAC for adults with acquired neurological conditions: A review. Augment Altern Commun, 2007; 23 (3):230-242.
  4. Rispoli MJ, Franco JH, van der Meer L, et al. The use of speech generating devices in communication interventions for individuals with developmental disabilities: a review of the literature. Dev Neurorehabil. 2010; 13(4):276-93.
  5. Medicare AAC Device Coverage Guidance. Local Coverage Determination. Speech Generating Devices (L108). Available at : http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=108&ContrId=139&ver=38&ContrVer=2&articleId=33679&CntrctrSelected=139*1&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=Washington&KeyWord=speech+generating+device&KeyWordLookUp=Title&KeyWordSearchType=And&%252520ncd_id=50.1&ncd_version=1&basket=ncd%25253A50%25252E1%25253A1%25253ASpeech+Generating+Devices&IsPopup=y&. Last accessed February, 2014.
  6. Centers for Medicare and Medicaid Services. Speech Generating Devices (SGD) Policy Article, (A33670). January 2011; revised November 2013. Available at : http://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=33679&ver=17&ContrId=139&ContrVer=2&CntrctrSelected=139*1&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=Washington&KeyWord=speech+generating+device&KeyWordLookUp=Title&KeyWordSearchType=And&%252520ncd_id=50.1&ncd_version=1&basket=ncd%25253A50%25252E1%25253A1%25253ASpeech+Generating+Devices&bc=gAAAABAAEAAAAA%3d%3d&. Last accessed February, 2014.
  7. AAC-RERC. Medicare Funding of AAC Technology. Supported in part by the National Institute on Disability and Rehabilitation Research (NIDRR). Web. Available at: http://aac-rerc.psu.edu/index.php/pages/show/id/5. Last accessed February, 2014.
  8. Policy reviewed by practicing Behavioral Health Specialist, November 2004, July 2007.
  9. Policy reviewed by a practicing Psychiatrist, March 2014.

Coding

Codes

Number

Description

CPT

92597

Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech

 

92607

Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour

 

92608

Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; each additional 30 minutes (List separately in addition to code for primary procedure)

 

92609

Therapeutic services for the use of speech-generating device, including programming and modification

 

31599

Unlisted procedure, larynx

HCPCS

E1399

Durable medical equipment, miscellaneous

 

E1902

Communication board, nonelectronic augmentative or alternative communication device

 

E2500

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

 

E2502

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

 

E2504

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

 

E2506

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

 

E2508

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

 

E2510

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

 

E2511

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

 

E2512

Accessory for speech generating device, mounting system

 

E2599

Accessory for speech generating device, not otherwise classified

Type of Service

Outpatient

DME

 

Place of Service

Home

 

Appendix

Speech generating devices (SGD), the Medicare nomenclature, has come into widespread use by speech language pathologists; rather than using the augmentative and alternative communication devices acronym “AAC”. (7)

History

Date

Reason

10/30/97

Add to Durable Medical Equipment Section - New Policy

10/06/98

Replace policy. Policy revised

12/10/02

Replace policy. Scheduled review

11/11/03

Replace policy. Scheduled review

01/01/04

Replace policy. CPT code updates only.

09/01/04

Replace policy. Policy renumbered from PR.1.01.102. No date changes.

12/14/04

Replace policy. Scheduled review. Policy statement revised to add autism as investigative. Rationale and References updated.

11/11/05

Replace policy. Scheduled review. Policy reviewed with literature search; no change to policy statement.

04/21/06

Codes Updated - No other changes

05/26/06

Update Scope and Disclaimer - No other changes.

12/12/06

Replace policy. Policy updated with literature review; references added. Investigational policy statement regarding treatment of speech and language disorders due to other pervasive developmental disorders removed and criteria added to Policy Guidelines section. Title changed to include, “Speech Generating Devices.”

10/9/07

Replace policy. Policy updated with literature review; references added; Investigational policy statement regarding management of speech and language disorders due primarily to autism and other PDD’s added.

03/11/08

Replace policy. Policy updated with literature search. Investigational policy statement regarding treatment of speech and language disorders due primarily to autism or other pervasive developmental disorders removed.

05/13/08

Cross Reference Update - No other changes

06/09/09

Replace policy. Policy updated with literature review; reference added. No change to the policy statement.

03/09/10

Replace policy. Policy updated with literature search no change to the policy statement. Codes added.

03/08/11

Replace policy. Policy updated with literature review; reference added. No change to the policy statement.

03/23/12

Replace policy. Policy updated with literature review; iPads added to the list of electronic devices in the Policy Guidelines which are not considered to be DME. No change to the policy statement.

07/25/12

Related Policies Update – 1.01.518 has been added.

02/13/13

Replace policy. Tablet computers added to replace the iPad brand in the list of devices in the Policy Guidelines. Added statement that patient record has documentation of ST evaluation and recommendations being sent to treating provider. Rationale section updated based on a literature review through January 2013. Rationale section reformatted to remove years without any literature updates. Medicare National Coverage Information added. Reference 6 added; others renumbered or removed. Policy statement unchanged.

05/13/13

Replace policy. At the request of HCDS, added statement to policy that artificial larynx are not addressed in this policy. The policy guidelines describe some of the devices considered to be prosthetics. Benefit application has an added statement to clarify least costly alternative may apply whether a DME or prosthetic item. Appendix has definition about nomenclature for speech generating devices. Minor edits for usability. Added larynx codes. Policy statement changed as noted. Add ICD-10 codes.

03/25/14

Replace policy. Policy reviewed. Reformatted for usability. Added definition of terms to Policy Guidelines with clarification that “Depending on where speech augmentation is needed, the AAC/SGD may be used in the home, school, work and/or community setting(s) when other criteria are met.” Policy updated with a literature search through January 2014. Reference 10 added; others renumbered/removed. Policy statement unchanged. Diagnosis codes (ICD-9 and ICD-10) removed from policy; these are not utilized for adjudication.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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