1. Aetna considers speech generating devices (SGDs) as medically necessary durable medical equipment (DME) for members who meet all of the following criteria: 
   1. Prior to the delivery of the SGD, the member has had a formal evaluation of their cognitive and language abilities by a speech-language pathologist (SLP).  The formal, written evaluation must include, at a minimum, all of the following elements:  
      1. A description of the functional communication goals expected to be achieved and treatment options; and
      2. A treatment plan that includes a training schedule for the selected device; and
      3. An assessment of whether the individual's daily communication needs could be met using other natural modes of communication; and 
      4. Demonstration that the member possesses the cognitive and physical abilities to effectively use the selected device and any accessories to communicate; and 
      5. Evaluation of current communication impairment, including the type, severity, language skills, cognitive ability, and anticipated course of the impairment; and 
      6. For a subsequent upgrade to a previously issued SGD, information regarding the functional benefit to the member of the upgrade compared to the initially provided SGD; and 
      7. Rationale for selection of a specific device and accessories;

         and 

   2. A copy of the SLP's written evaluation and recommendation have been forwarded to the member's treating physician prior to ordering the device; and  
   3. Other forms of treatment have been considered and ruled out; and  
   4. The member’s medical condition is one resulting in a permanent severe expressive speech disability; and 
   5. The member's speaking needs can not be met using natural communication methods; and  
   6. The member's speech disability will benefit from the device ordered; and   
   7. The SLP performing the evaluation of the member may not be an employee or have a financial relationship with the supplier of the SGD.  

2. Aetna considers SGDs experimental and investigational when criteria are not met.

Accessories and upgrades for the SGD are considered medically necessary if the basic medical necessity criteria are met and the medical necessity for each accessory is clearly documented in the formal evaluation by the SLP.

Only 1 SGD or speech generating software program at a time is considered medically necessary per member.

Multi-lingual modules for SGDs are considered not medically necessary.

Notes: Laptop computers, desktop computers, personal digital assistants (PDAs), or other devices that are not dedicated SGDs are not covered because they do not meet the definition of DME.  Please check benefit plan descriptions for details.

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

There should be no separate billing of any software, interfaces, cables, adapters, interconnects, and switches necessary for the accessory to interface with the SGD.

Note: SGDs, as described above, are considered medically necessary regardless of whether the plan has an exclusion for "communication aids."  Communication aids that are not SGDs are not covered under plans that exclude communication aids.  Please check benefit plan descriptions for details. 

Note: This CPB does not apply to electronic speech aids that are used by laryngectomized persons and persons with a permanently inoperative larynx.  These are considered prosthetics.  There are 2 types of electronic speech aids.  One operates by placing a vibrating head against the throat.  The other amplifies sound waves through a tube which is inserted into the user's mouth.  A person who has had radical neck surgery and/or extensive radiation to the anterior part of the neck would generally be able to use only the "oral tube" model or one of the sensitive and more expensive "throat contact" devices.

This policy is based on Medicare DMERC criteria for speech generating devices (SGDs), which are speech aids that provide individuals with severe speech impairment the ability to meet their functional speaking needs.  Digitized speech, sometimes referred to as devices with "whole message" speech output, use words or phrases that have been recorded by an individual other than the SGD user for playback upon command of the SGD user.

Synthesized speech, unlike pre-recorded messages of digitized speech, is a technology that translates a user's input into device-generated speech using algorithms representing linguistic rules.  Users of synthesized speech SGDs are not limited to pre-recorded messages but rather can independently create messages as their communication needs dictate.  Some SGDs require message formulation by spelling and access by physical contact with a keyboard, touch screen, or other display containing letters.  Speech generating software programs enable a laptop computer, desktop computer or personal digital assistant (PDA) to function as an SGD.  Within this policy, the term SGD also describes these speech generating software programs.  Speech generating devices may permit multiple methods of message formulation and multiple methods of device access.  For purposes of this policy, a SGD with multiple methods of message formulation should include message selection by 2 or more of the following methods: letters, words, pictures, and symbols.  A SGD with multiple methods of access should include the capability to access the device by 2 or more of the following: direct physical contact with a keyboard or touch screen, indirect selection techniques and a specialized access device such as a joystick, head mouse, optical head pointer, light pointer, infrared pointer, scanning device, or Morse code.

Upgrades of a SGD are subsequent versions of a SGD's software program or memory modules that may include enhanced features or other improvements.  Mounting switches are devices necessary to place the SGD, switches, and other access devices within the reach of the patient.

Accessories for SGDs include, but are not limited to, access devices that enable selection of letters, words, or symbols via direct or indirect selection techniques.  Examples of access devices include, but are not limited to, optical head pointers, joysticks, and SGD scanning devices.  The assessment of need for an SGD should be performed by a qualified speech-language pathologist (SLP).  For purposes of this policy, SLPs are licensed health professionals trained in the diagnosis and treatment of speech and language disorders.  The SLP should hold a Certificate of Clinical Competence from the American Speech and Hearing Association.

Communication aids that do not generate speech are not covered under most Aetna benefit plans, as most plans have a specific contractual exclusion of communication aids.  Please check benefit plan descriptions for details.  In addition, communication aids that are not SGDs are not considered prosthetics for speech, as they do not replace internal or external body parts lost or impaired by disease or injury.  Examples of non-covered communication aids include the following: picture books; flashcards; Braille typewriters; TTY (text telephone or TDD) devices; devices that allow the patient to communicate messages to others with writing (e.g., a display screen or printout) rather than with synthesized speech; and devices that allow the user to communicate with a computer rather than with another person.  Although communication aids that do not generate (synthesize) speech may be useful to patients who otherwise can not communicate, they do not meet the definition of a prosthetic device under Aetna's benefit plans.

In addition, these communication aids that are not SGDs do not meet the definition of covered durable medical or surgical equipment under Aetna's benefit plans.  Aetna's DME benefit covers medical or surgical equipment for treatment of disease or injury; or for the purpose of improving body function lost or impaired by disease or injury; or to enable the patient to perform essential activities of daily living related to the patient's health and hygiene, within or outside the home, with minimal or no assistance from others.  Aetna does not consider communication to be a bodily function.  Although communication may be considered an activity of daily living, it is an activity that is not related to the patient's health and hygiene.  Examples of functions and essential activities of daily living for which Aetna covers DME include bathing; feeding; toileting; walking; and transferring from bed to chair, wheelchair or walker.  Aetna does not consider communication to be an activity of this type.  Furthermore, patients requiring a communication aid are usually unable to perform any of these functions without assistance from others, with or without a communication aid.

The literature for some communication aids emphasize their value in expanding vocabulary skills, for use in business and for report preparation, and their ability to be connected to a personal computer.  This goes beyond what is considered to be an essential medical device.  For similar reasons, Aetna does not cover visual alert systems for the deaf or special controls on cars for people who need them to drive.

Speech may gradually improve after head trauma or stroke.  For these acquired disorders, SGDs are used as a last option.  Therefore, use of an SGD is not usually initated less than 4 to 6 months after trauma or stroke.

Medicare classifies SGDs as DME.  To be eligible for an SGD, Medicare requires that the beneficiary is enrolled in Medicare Part B; the beneficiary lives in his/her family home, or an assisted living facility (but not in a hospital, skilled nursing facility, or hospice); the beneficiary is determined, following an assessment by a SLP, to require an SGD to meet daily functional communication needs; and the beneficiary's physician prescribes the SGD.

Rispoli and colleagues (2010) reviewed communication interventions that involved the use of SGD for individuals with developmental disabilities.  Systematic searches of electronic databases, journals and reference lists identified 35 studies meeting the inclusion criteria.  These studies were evaluated in terms of (i) participants, (ii) SGD function, (iii) SGD characteristics, (iv) intervention procedures, (v) intervention results and (vi) certainty of evidence.  Across these studies, intervention was provided to a total of 86 subjects aged 1 to 42 years.  Communication skills targeted included requesting, social or conversational skills, labeling items and receptive language.  Intervention approaches were categorized as using Discrete Trial Training, Milieu teaching or a combined instructional approach.  Positive outcomes were reported in 86 % of the studies with 54 % of studies categorized as providing conclusive evidence.  The authors concluded that this literature base is considered promising due to the large number of conclusive studies and the replication of intervention approaches.

van der Meer and Rispoli (2010) reviewed communication intervention studies that involved the use of SGD for children with autism.  A total of 23 studies were identified that met the inclusion criteria following systematic searches of electronic databases, journals and reference lists.  Studies were evaluated in terms of: (i) participants, (ii) setting, (iii) mode of communication, (iv) communication skill(s) taught to the participant, (v) intervention procedures, (vi) outcomes, (vii) follow-up and generalization, (viii) reliability and treatment integrity and (ix) design and certainty of evidence.  Intervention, most commonly targeting requesting skills, was provided to a total of 51 children aged 3 to 16 years.  Intervention strategies followed 2 approaches: (i) operant/behavioral techniques and (ii) naturalistic teaching procedures.  Positive outcomes were reported for 86 % of the studies and 78 % of the studies were categorized as providing conclusive evidence.  The authors concluded that the literature base suggests that SGDs are viable communication options for children with autism.  However, they stated that several areas warrant future research.