HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
E-36-018
Topic:
Speech Generating Devices
Section:
Durable Medical Equipment
Effective Date:
April 9, 2018
Issued Date:
January 28, 2019
Last Revision Date:
January 2019
Annual Review:
January 2019
 
 

Speech generating devices (SGDs) are speech aids that provide individuals with severe speech impairment the ability to meet their functional speaking needs. SGDs provide digitized speech as well as synthesized speech. However, SGDs do not include external speech processors that are part of a cochlear device/system used to capture and amplify sound.

Policy Position

SGDs may be considered medically necessary when ordered by the treating physician and ALL of the following criteria are met:

  • A formal evaluation of the individual’s cognitive and communication abilities have been performed by a Speech Language Pathologist (SLP). The findings of this evaluation must be documented as a formal written evaluation and forwarded to the individual’s treating physician prior to the device being ordered. The written evaluation must include ALL of the following elements:
    • Current communication impairment, including the type, severity, language skills, cognitive ability, and anticipated course of the impairment; and
    • An assessment of whether the individual’s daily communication needs could be met using other natural modes of communication; and
    • A description of the functional communication goals expected to be achieved and treatment options; and
    • Rationale for selection of a specific device and any accessories; and
    • Demonstration that the  individual possesses the cognitive and physical abilities to effectively use the selected device and any accessories to communicate; and
    • A treatment plan that includes a training schedule for the selected device; and
    • For a subsequent upgrade to a previously issued SGD, information regarding the functional benefit to the  individual of the upgrade compared to the initially provided SGD; and
  • The  individual’s medical condition is one resulting in a severe expressive speech impairment; and
  • The individual’s speaking needs cannot be met using natural communication methods; and
  • Other forms of treatment have been considered and ruled out; and
  • The individual’s speech impairment will benefit from the device ordered.

Accessories may be considered medically necessary if the coverage criteria for the base device are met and the medical necessity for each accessory is clearly documented in the formal written evaluation by the SLP. Speech pathology services pertaining to the individual’s evaluation and training in use of these devices may also be considered medically necessary.

If all the SGD coverage criteria are not met, the SGD will be denied as not medically necessary. When the SGD is not covered, accessories are also not covered.

Requests for more than one SGD will be denied as not medically necessary.

Laptop computers, desktop computers, personal digital assistant s (PDAs) or other devices that are not dedicated SGDs are not covered because they do not meet the definition of durable medical equipment (DME). This is a benefit denial.

Communication aids that are not speech generating devices (e.g., communication boards) do not meet the definition of DME. Therefore, they are benefit denials. In addition, services related to non-speech generating devices are also not covered.  

Related Components and Accessories for SGDs

The SGD and its components may not be billed separately.

Speech generating software programs enabling a laptop computer, desktop computer or PDA to function as an SGD may be considered medically necessary as a SGD within the terms of this policy. Installation of the program or technical support is not separately reimbursable.

Separate billing should not be made for any software, interfaces, cables, adapters, interconnects, or switches necessary for the accessory to interface with the SGD.

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92606

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92609

92618

E1902

E2500

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E2504

E2506

E2508

E2510

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E2515

E2599

V5336

 

 

 

 




Eye gaze or eye glance technology (e.g., DynaVox EyeMax System) may be considered medically necessary for an individual who meets the requirements for a SGD as documented on this policy, but has limited use of his or her extremities that renders the individual unable to control or sustain fine/gross body movements that would enable him or her to access an SGD using more conventional access methods such as switches or direct touch. The individual must have direct vision in one or both eyes, and for full control over the system, should have the ability to look up, down, left and right. The individual must also have adequate vision to view the screen, and must have the ability to focus on one spot for a brief period of time. Contraindications include, but may not be limited to, those individuals with the following conditions: continuous, uncontrolled head movement; nystagmus. It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage for eye gaze access devices.

Services not meeting the above criteria are considered not medically necessary. 

E2599

 

 

 

 

 

 




Place of Service: Outpatient

The use of a Speech Generating Device is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

    Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.