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), portable multi-media players (e.g., iPod), smart phones, and tablet devices (e.g., Galaxy, 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.
Lorah et al (2014) stated that powerful, portable, off-the-shelf handheld devices, such as tablet based computers (i.e., iPad; Galaxy) or portable multi-media players (i.e., iPod), can be adapted to function as SGDs for individuals with autism spectrum disorders or related developmental disabilities. These investigators reviewed the research in this new and rapidly growing area and delineated an agenda for future investigations. In general, participants using these devices acquired verbal repertoires quickly. Studies comparing these devices to picture exchange or manual sign language found that acquisition was often quicker when using a tablet computer and that the vast majority of participants preferred using the device to picture exchange or manual sign language. The authors concluded that future research in interface design, user experience, and extended verbal repertoires is recommended.
|CPT Codes / HCPCS Codes / ICD-9 Codes|
|CPT codes covered if selection criteria are met:|
|92521||Evaluation of speech fluency (eg, stuttering, cluttering)|
|92522||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)|
|92523||Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)|
|92524||Behavioral and qualitative analysis of voice and resonance|
|92605||Evaluation for prescription of non-speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour|
|92607||Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour|
|+ 92608||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|
|92618||Evaluation for prescription of non-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)|
|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)|
|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|
|784.5||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|