Clinical UM Guideline


Subject:Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)
Guideline #:  CG-DME-07Current Effective Date:  10/08/2013
Status:ReviewedLast Review Date:  08/08/2013

Description

Augmentative and alternative communication (AAC) devices and speech generating devices (SGD) are aids to provide individuals with severe speech impairment or absent speech, the ability to meet their functional communication needs.  There may be associated functional disabilities that also limit the individual's ability to use alternative natural methods of communication such as writing notes, using sign language, or even to manipulate a low tech augmentative communication system.

Clinical Indications

Medically Necessary:

Augmentative and alternative communication and speech generating devices and systems are considered medically necessary when all of the following criteria 1 through 3 are met, and when applicable, criteria 4 or 5 are met:

  1. The device has been recommended by the individual's physician and licensed speech language pathologist who has conducted and documented a thorough assessment which includes all of the following information:
    1. Medical diagnosis, physiological description of the underlying disorder, description of functional limitation, nature and severity of speech or communication impairment, and prognosis for improvement (or deterioration); and
    2. Medical justification for the device, and if a high tech* device is requested, it is demonstrated that a low tech* communication device or system is inadequate to meet the individual's functional communication needs; and 
    3. Therapeutic history including speech, occupational, or physical therapies as appropriate; and
    4. Documentation of the cognitive ability to utilize the selected device; and 
    5. Documentation of the visual, auditory, language and motor ability to utilize the selected device; and 
    6. Documentation of the specific daily functional communication needs; and 
    7. Expected functional communication goals with the device; and 
    8. Plan of care for the device: anticipated training needs, programming needs, evaluations, etc.; AND
  2. The individual has severe expressive speech impairment and alternative natural communication methods such as writing or sign language are not feasible or are inadequate for that individual's daily functional communication needs; AND
  3. The individual has tested the device, has demonstrated the ability to use the device and there is documentation of the rationale for the specific device selected.
  4. If the individual has a degenerative disease causing the speech impairment, the communication device selected should be capable of modification to meet the individual's anticipated needs.
  5. If the individual is preliterate but it is anticipated that he or she will be able to learn to read and spell, the communication device selected should in addition have spelling and text capabilities.

*Refer to Discussion/General Information section of the clinical guideline for information on high technology and low technology devices.

Accessories are considered medically necessary if criteria for the base device are met and the medical necessity for each accessory is clearly documented in the formal evaluation by the speech language pathologist.  For any subsequent upgrade of equipment or accessories to a previously issued device, information regarding the functional benefit to the individual of the upgrade compared to the initially provided device must be submitted to demonstrate medical necessity.

When the above criteria 1 through 3 are met, and when applicable, criteria 4 or 5 are met, specific communication software for dedicated speech generating devices is considered medically necessary.

Not Medically Necessary:

Augmentative communication devices and speech generating devices/systems are considered not medically necessary if the above criteria are not met or if they are not primarily and customarily used to serve a medical purpose.

The following would also be considered not medically necessary:

  1. Devices that are not dedicated speech devices, but are devices that are capable of running software for purposes other than for speech generation, e.g. devices that can also run a word processing program or perform other non-medical functions.
  2. Laptop, tablet or desktop computers, personal digital assistants (PDAs) or other devices which may be programmed to perform the same function as a speech generating device.
Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS 
 Devices
E1902Communication board, non-electronic augmentative or alternative communication device
E2351Power wheelchair accessory, electronic interface to operate speech generating device using power wheelchair control interface
E2500Speech generating device, digitized speech, using prerecorded messages, less than or equal to 8 minutes recording time
E2502Speech generating device, digitized speech, using prerecorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time
E2504Speech generating device, digitized speech, using prerecorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time
E2506Speech generating device, digitized speech, using prerecorded messages, greater than 40 minutes recording time
E2508Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device
E2510Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access
  
 Artificial larynx and accessories
L8500Artificial larynx, any type
L8501Tracheostomy speaking valve
L8507Tracheo-esophageal voice prosthesis, patient inserted, any type, each
L8509Tracheo-esophageal voice prosthesis, inserted by a licensed health care provider, any type
L8510Voice amplifier
  
ICD-9 Diagnosis 
 All diagnoses
  
ICD-10 DiagnosisICD-10-CM draft codes; effective 10/01/2014
 All diagnoses
  
Discussion/General Information

Augmentative and alternative communication (AAC) devices/speech generating devices (SGD) are speech aids to provide individuals with severe speech impairment or absent speech, the ability to meet their functional communication needs.  Etiologies of speech impairment in children may include cerebral palsy, mental retardation, autism-like disorders and other genetic or speech disorders.  Etiologies in adults may include stroke, traumatic brain injury, amyotrophic lateral sclerosis (ALS), Parkinson's disease and head and neck cancers among others.  There may be associated functional disabilities that also limit the individual's ability to use alternative natural methods of communication such as writing notes, using sign language, or even to manipulate a low tech augmentative communication system.

There are numerous communication devices currently available from multiple manufacturers.  Low technology, non-electronic AAC devices include boards that use letters, words, phrases and/or symbols (communication boards), mini boards, schedule boards, and conversation books.  They may be purchased, homemade, or developed by the speech therapist.

High technology devices are electronic, generally SGDs, and usually computer-based.  Digitized speech generating devices, 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.  The time available for pre-recorded messages varies.  Synthesized speech is a technology that translates a user's input into device-generated speech using algorithms representing linguistic rules.  Users of synthesized SGDs are not limited to pre-recorded messages, but instead can independently create messages as their communication needs dictate.  Some SGDs require a 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.

An extra-oral electrolarynx type device (primarily for use post-laryngectomy) consists of a hand-held sound generator which transmits sound waves through the skin and muscle of the neck, vibrating the air column in the vocal tract and allowing for verbal communication.  An intra-oral electrolarynx type device is also available, consisting of a handheld control unit transmitting radio waves to an intra-oral radio control circuit which, together with a loudspeaker, is mounted to a denture or orthodontic retainer. It is claimed to produce a more natural sounding voice than other technologies.

A systematic review by Rispoli and colleagues (2010) 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."

Definitions

Digitalized speech: Devices with "whole message" speech output utilize words or phrases recorded by another individual.

Laryngectomy: Surgical removal of the voice box.

Speech disorder: A condition affecting the ability to produce normal speech may affect articulation (phonetic or phonological disorders); fluency (stuttering or cluttering); and/or voice (tone, pitch, volume, or speed); most speech disorders have their roots in the muscles of the mouth and/or mouth movements.

Speech language pathologist: Another title for a Speech Therapist.

Synthesized speech: A technology that translates a user's input into device-generated speech.

References

Peer Reviewed Publications:

  1. Ansel BM, Weinrich M. Computerized approaches to communication retraining after stroke. Curr Atheroscler Rep. 2002; 4(4):291-295.
  2. Baxter S, Enderby P, Evans P, Judge S. Barriers and facilitators to the use of high-technology augmentative and alternative communication devices: a systematic review and qualitative synthesis. 2012; 47(2): 115-129.
  3. Downey M, Hurtig R. Augmentative and alternative communication. Pediatr Ann. 2003; 32(7):466-474.
  4. Drager KD, Clark-Serpentine EA, Johnson KE, Roeser JL. Accuracy of repetition of digitized and synthesized speech for young children in background noise. Am J Speech Lang Pathol. 2006; 15(2):155-164.
  5. Drager KD, Reichle J, Pinkoski C. Synthesized speech output and children: a scoping review. Am J Speech Lang Pathol. 2010; 19(3):259-273.
  6. Ganz JB, Earles-Vollrath TL, Heath AK, et al. A meta-analysis of single case research studies on aided augmentative and alternative communication systems with individuals with autism spectrum disorders. J Autism Dev Disord. 2012; 42(1):60-74.
  7. Hustad KC, Keppner K, Schanz A, Berg A. Augmentative and alternative communication for preschool children: intervention goals and use of technology. Semin Speech Lang. 2008; 29(2):83-91.
  8. Rispoli M, 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.
  9. Schlosser RW, Wendt O. Effects of augmentative and alternative communication intervention on speech production in children with autism: a systematic review. Am J Speech Lang Pathol. 2008; 17(3):212-230.
  10. 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.
  11. van der Meer L, Sigafoos J, O'Reilly MF, Lancioni GE. Assessing preferences for AAC options in communication interventions for individuals with developmental disabilities: A review of the literature. Res Dev Disabil. 2011; 32(5):1422-1431.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Centers for Medicare and Medicaid Services. National Coverage Determination: Durable Medical Equipment Reference List. NCD #280.1. Effective May 5, 2005. Available at: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=280.1&ncd_version=2&basket=ncd%3A280%2E1%3A2%3ADurable+Medical+Equipment+Reference+List. Accessed on June 26, 2012.
  2. Centers for Medicare and Medicaid Services. National Coverage Determination: Electronic Speech Aids. NCD #50.2. Effective date not posted. Available at:  http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=50.2&ncd_version=1&basket=ncd%3A50%2E2%3A1%3AElectronic+Speech+Aids. Accessed on June 26, 2012. 
  3. Centers for Medicare and Medicaid Services. National Coverage Determination: Speech Generating Devices. NCD #50.1. Effective January 1, 2001. Available at: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=50.1&ncd_version=1&basket=ncd%3A50%2E1%3A1%3ASpeech+Generating+Devices. Accessed on June 21, 2013.
Web Sites for Additional Information
  1. National Institute on Deafness and Other Communication Disorders (NIDCD). Assistive devices for people with hearing, voice, speech or language disorders. 2011. Available at: http://www.nidcd.nih.gov/health/hearing/Pages/Assistive-Devices.aspx?nav=update. Accessed on June 21, 2013.
Index

Augmentative and Alternative Communication (AAC) Devices
Communication Devices
Digital Speech
Speech Generating Devices (SGD)
Speech Impairment
Synthesized Speech

History
StatusDateAction
Reviewed08/08/2013Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References and Websites. Added Web Sites for Additional Information section.
Revised08/09/2012MPTAC review. Clarified not medically necessary statement. Updated Coding, Discussion/General Information, References and Websites.
 01/01/2012Updated Coding section with 01/01/2012 CPT changes.
Reviewed08/18/2011MPTAC review. Updated Coding, References and Websites.
Reviewed08/19/2010MPTAC review. Updated References and Websites.
Reviewed08/27/2009MPTAC review. Removed Place of Service Section.
Reviewed08/28/2008MPTAC review. Formatting corrected in medical necessity section. Separated software criteria and moved into the medical necessity section.  Updated coding section with 10/01/2008 ICD-9 changes.
Reviewed08/23/2007MPTAC review. Formatting corrected in medical necessity section. Updated definitions and references. No change to position.
Reviewed09/14/2006MPTAC review. No change in position.
 11/22/2005Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).
Reviewed09/22/2005MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger Organizations

Last Review Date

Document Number

Title

 

Anthem, Inc.

 

  
Anthem BCBS

09/23/2004

Anthem West: DME.220Speech Generating Devices
Anthem BCBS

10/01/2004

Anthem CTDurable Medical Equipment Summary of Coverage Criteria Guidelines
WellPoint Health Networks, Inc.

07/14/2005

9.03.05Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)