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Aetna Aetna
Clinical Policy Bulletin:
Speech Generating Devices
Number: 0437


Policy

  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: Desktop computers, laptop computers, pagers, personal digital assistants (PDAs), smart phones, and tablet devices (e.g., iPads), 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.



Background

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.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
92521
92522
92523
92524
92605
92607
+ 92608
92609
92618
HCPCS codes covered if selection criteria are met:
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
G0153 Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes
V5336 Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid)
V5362 Speech screening
V5363 Language screening
HCPCS codes not covered for indications listed in the CPB:
E1902 Communication board, nonelectronic augmentative or alternative communication device
Other HCPCS codes related to the CPB:
L8500 Artificial larynx, any type
L8505 Artificial larynx replacement battery/accessory, any type
ICD-9 codes covered if selection criteria are met:
315.31 - 315.39 Developmental speech or language disorder
438.10 - 438.19 Late effects of cerebrovascular disease, speech and language deficits
784.3 Aphasia
784.5 Other speech disturbance
Other ICD-9 codes related to the CPB:
161.0 - 161.9 Malignant neoplasm of larynx
191.0 - 191.9 Malignant neoplasm of brain
433.00 - 436 Occlusion and stenosis of precerebral or cerebral arteries, transient cerebral ischemia, and acute, but ill-defined, cerebrovascular disease
800.00 - 801.99 Fracture of vault of skull, base of skull
850.0 - 854.19 Intracranial injury, excluding those with skull fracture
905.0 Late effect of fracture of skull and face bones
907.0 Late effect of intracranial injury without mention of skull fracture
V10.02 Personal history of malignant neoplasm of other and unspecified oral cavity and pharynx
V10.85 Personal history of malignant neoplasm of brain


The above policy is based on the following references:
  1. U.S. Department of Health and Human Services, Health Care Financing Administration (HCFA). Speech generating devices. Medicare Coverage Issues Manual §60-23. HCFA Pub. 6. Baltimore, MD: HCFA; 2001.
  2. NHIC, Corp. Speech generating devices. Medicare Local Coverage Determination (LCD). Durable Medical Equipment Medicare Administrative Contractor (DME MACZ) Jurisdiction A. LCD Database ID No. L11534. Contractors Determination No. SGD. Hingham, MA: NHIC; effective January 1, 2011.
  3. NHIC, Corp. Speech generating devices. Policy Article. Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdication A. Article Database ID No. A33770. Hingham, MA: NHIC; effective January 1, 2011.
  4. U.S. Department of Health and Human Services, Health Care Financing Administration (HCFA). Durable medical equipment reference list. Medicare Coverage Issues Manual §60-9. HCFA Pub. 6. Baltimore, MD: HCFA; 2001.
  5. Poole CJ, Millman A. ABC of medical computing. Adaptive computer technology. Br Med J. 1995;311(7013):1149-1151.
  6. Tolley K, Leese B, Wright K, et al. Communication aids for the speech impaired: Cost and quality-of-life outcomes of assessment programs provided by specialist communication aids centers in the United Kingdom. Int J Technol Assess Health Care. 1995;11(2):196-213.
  7. Pehringer JL. Assistive devices: Technology to improve communication. Otolaryngol Clin North Am. 1989;22(1):143-174.
  8. Redford JB. Assistive devices. In: Practice of Geriatrics. 3rd Ed. EH Duthie, JR Katz, eds. Philadelphia, PA: W.B. Saunders Co.; 1998: 173-186.
  9. Rostron A, Ward S, Plant R. Computerized augmentative communication devices for people with dysphasia: Design and evaluation. Eur J Discord Commun. 1996;31(1):11-30.
  10. Beukelman DR, Mirenda P. Augmentative and alternative communication: Management of severe communication disorders in children and adults. Baltimore, MD: P.H. Brookes Publishers; 1998.
  11. Lloyd LL, Fuller DR, Arvidson HH. Augmentative and alternative communication: A handbook of principles and practices. Boston, MA: Allyn and Bacon; 1997.
  12. Bergen AF. Assistive technology for disabled clients. Caring. 1998;17(1):18-27.
  13. Wood D. Talking again with the help of a communication device. EBSCO Health Library. Ipswich, MA: EBSCO Publishing; 2005. Available at: http://healthlibrary.epnet.com/print.aspx?token=723d4f33-4765-4183-9518-055337ce86f8&chunkiid=24025. Accessed June 20, 2006.
  14. Schlosser RW, Sigafoos J. Augmentative and alternative communication interventions for persons with developmental disabilities: Narrative review of comparative single-subject experimental studies. Res Develop Disabil. 2006;27(1):1-29.
  15. Millar DC, Light JC, Schlosser RW. The impact of augmentative and alternative communication intervention on the speech production of individuals with developmental disabilities: A research review. J Speech Lang Hear Res. 2006;49(2):248-264.
  16. Bruno J, Trembath D. Use of aided language stimulation to improve syntactic performance during a weeklong intervention program. Augment Altern Commun. 2006;22(4):300-313.
  17. Saito Y, Turnbull A. Augmentative and alternative communication practice in the pursuit of family quality of life: A review of the literature. Res Pract Severe Disabil. 2007;32(1):50-65.
  18. Olive ML, de la Cruz B, Davis TN, et al. The effects of enhanced milieu teaching and a voice output communication aid on the requesting of three children with autism. J Autism Dev Disord. 2007;37(8):1505-1513.
  19. Thunberg G, Ahlsén E, Sandberg AD. Children with autistic spectrum disorders and speech-generating devices: Communication in different activities at home. Clin Linguist Phon. 2007;21(6):457-479.
  20. Tack JW, Qiu Q, Schutte HK, et al. Clinical evaluation of a membrane-based voice-producing element for laryngectomized women. Head Neck. 2008;30(9):1156-1166.
  21. Shepherd TA, Campbell KA, Renzoni AM, Sloan N. Reliability of speech generating devices: A 5-year review. Augment Altern Commun. 2009;25(3):145-153.
  22. Rodriguez C, Rowe M. Use of a speech-generating device for hospitalized postoperative patients with head and neck cancer experiencing speechlessness. Oncol Nurs Forum. 2010;37(2):199-205.
  23. 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):276-293.
  24. van der Meer LA, Rispoli M. Communication interventions involving speech-generating devices for children with autism: A review of the literature. Dev Neurorehabil. 2010;13(4):294-306.
  25. van der Meer L, Kagohara D, Achmadi D, et al. Speech-generating devices versus manual signing for children with developmental disabilities. Res Dev Disabil. 2012;33(5):1658-1669.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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