Speech generating devices (SGDs) are eligible for reimbursement when ordered by the treating physician and all of the following criteria are met:

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

Accessories (E2599) are also covered 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 speech-language pathologist (SLP). Speech pathology services pertaining to patient evaluation and training in use of these devices (92607-92609) may also be reimbursed.

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. In these instances, a participating, preferred, or network provider cannot bill the member for the denied SGD or the denied accessories.

Codes E2500-E2511 perform the same essential function – speech generation. Therefore, requests for more than one SGD will be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.

Laptop computers, desktop computers, PDAs or other devices that are not dedicated SGDs are not covered because they do not meet the definition of DME. This is a benefit denial. As such, a participating, preferred, or network provider can bill the member for the denied service.

Communication aids that are not speech generating devices (e.g., communication boards [E1902]) do not meet the definition of durable medical equipment (DME). Therefore, they are benefit denials. A participating, preferred, or network provider can bill the member for the denied service. In addition, services related to non-speech generating devices (e.g., 92605, 92606) are also not covered and can be billed to the member.

Related Components and Accessories for SGDs

Codes E2500-E2510 include the device, any applicable software, batteries, battery chargers, and AC adapters. These items may not be billed separately.

Upgrades to E2500-E2510 are subsequent versions of the device’s software program or memory modules that may include enhanced features or other improvements, and should be coded as E2599.

Speech generating software programs (E2511) enable a laptop computer, desktop computer or personal digital assistant (PDA) to function as an SGD. These devices are not dedicated SGDs. However, within this policy, the term SGD also describes these speech generating software programs. As such, this software (E2511) is covered as an SGD. Installation of the program or technical support is not separately reimbursable.

Code E2511 must not be used to code software included with the initial provision of the SGD (E2500-E2510), since the software cost is included in the reimbursement for those SGD codes. In addition, code E2511 must not be used to request software included with the initial provision of the access device (E2599) since the software cost is included in the reimbursement for the access device. However, upgrades to E2511 are subsequent versions of a speech generating software program that may include enhanced features or other improvements, and may be coded E2511.

Accessories for speech generating devices (E2599) 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, switches, wheelchair integration devices and SGD scanning devices. In addition, replacement accessories such as batteries, battery chargers and AC adapters are included in this code. However, a separate billing should not be made for any software, interfaces, cables, adapters, interconnects, or switches necessary for the accessory to interface with the SGD (E2500-E2510).

Coverage for DME is determined according to individual or group customer benefits.

NOTE:

Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME. For information on continuous rental of life sustaining DME, see Medical Policy Bulletin E-38, Continuous Rental of Life Sustaining Durable Medical Equipment (DME).

Description

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. See Medical Policy Bulletin S-67, Cochlear Implantation, for information on cochlear devices.

Types of SGDs

• Digitized speech (E2500-E2506) utilizes words or phrases, sometimes referred to as “whole message” speech output. These “whole messages” have been recorded by an individual other than the SGD user for playback upon command of the SGD user.
• Synthesized speech (E2508, E2510) is a technology that translates a user’s input into device-generated speech. Users of synthesized speech SGDs are not limited to pre-recorded messages. Messages, dictated by the needs of the user, can be independently created.

E2508 devices require that the user make physical contact with a keyboard, touch screen or other display containing letters.

E2510 devices permit the user multiple methods of message formulation and multiple methods of device access. Multiple methods of message formulation must include the capability for message selection by two or more of the following methods: letters, words, pictures or symbols. Multiple methods of access must include the capability to access the device by two or more of the following: direct physical contact with a keyboard or touch screen, indirect selection techniques with a specialized access device such as a joystick, head mouse, optical head pointer, switch, light pointer, infrared pointer, scanning device, or Morse Code.

Devices that have the capability to generate both digitized and synthesized speech must be coded E2508 or E2510, depending on the method of synthesized speech formulation and device access.

Personal digital assistants (PDAs) are handheld devices that integrate the functions of a small computer with features such as a cell phone, personal organizer, electronic mail or pager. Information may be input via a pen-based system using a stylus and handwriting recognition software, keyboard or downloaded from a personal computer using special cables and software.

Mounting systems (E2512) are devices necessary to place the SGD device, switches, and other access devices within the reach of the patient.

NOTE:

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 circumstances may warrant individual consideration, based on review of applicable medical records.

SGDs and related services are not covered under FEP.

PRN References

06/2002, Blue Shield allows speech generating devices, patient must meet certain criteria

DMERC Region A MPB 14.32
MCIM 60-9, 60-23