Clinical UM Guideline

 

Subject: Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)
Guideline #:  CG-DME-07 Publish Date:    08/29/2018
Status: Revised Last Review Date:    07/26/2018

Description

This document addresses augmentative and alternative communication (AAC) devices and speech generating devices (SGD).

AAC and SGD devices are aids to improve the functional communication needs of individuals with severe speech impairment or absent speech.  Associated functional disabilities may limit an individual’s ability to use alternative natural methods of communication such as writing notes, using sign language, or even to manipulate a low technology 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 A through C are met, and when applicable, criteria D or E are met:

  1. The device has been recommended by the individual’s physician and licensed speech language pathologist who have each 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 technology (electronic such as digitized speech generating device) device is requested, it is demonstrated that a low technology (non-electronic such as communication board) 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.

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 A through C are met, and when applicable, criteria D or E 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 are 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, for example, 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. 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

E1902

Communication board, non-electronic augmentative or alternative communication device

E2351

Power wheelchair accessory, electronic interface to operate speech generating device using power wheelchair control interface

E2500

Speech generating device, digitized speech, using prerecorded messages, less than or equal to 8 minutes recording time

E2502

Speech generating device, digitized speech, using prerecorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time

E2504

Speech generating device, digitized speech, using prerecorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time

E2506

Speech generating device, digitized speech, using prerecorded 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

 

 

 

Artificial larynx and accessories

L8500

Artificial larynx, any type

L8501

Tracheostomy speaking valve

L8507

Tracheo-esophageal voice prosthesis, patient inserted, any type, each

L8509

Tracheo-esophageal voice prosthesis, inserted by a licensed health care provider, any type

L8510

Voice amplifier

 

 

ICD-10 Diagnosis

 

 

All diagnoses

Discussion/General Information

AAC devices and 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, intellectual/developmental disorder, 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, pictures 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, tablet or desktop computer or personal digital assistants (PDAs) 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.

The published literature supporting the use of AAC devices and SGD consists of case reports and small case series.  In addition, there have been a number of systematic reviews of those studies (Ganz, 2017; Ganz, 2014; Ganz, 2012; Rispoli, 2010; Russo, 2017). Most recently, in 2017, Ganz and colleagues published a systematic review of studies on high-technology AAC devices for individuals with intellectual/developmental disabilities and complex communication needs.  The review identified 24 studies with a total of 56 participants. Studies evaluated different interventions and outcome measures varied.  All of the interventions provided statistically significant benefits, compared with baseline and the overall pooled effect size was 0.70 (95% CI [confidence interval; 0.63 to 0.77]).

A 2014 systematic review by Ganz and colleagues included 35 studies with a total of 81 participants who had intellectual/developmental disorders and autism spectrum disorder (ASD).  The study analyzed if the effectiveness of Picture Exchange Communication Systems (PECS), SGDs and other picture-based AAC were moderated by the characteristics of the individuals who utilized the devices.  Although SGDs were significantly more effective for individuals with ASD without any comorbid disability and PECS were more effective for individuals with ASD and IDD, these conclusions were based on subsets consisting of fewer studies (9 studies and 5 studies, respectively).  The use of PECS and SGDs demonstrated improvement in speech production for very young children, but not for elementary-age or older individuals as well as older participants. 

A systematic review of studies on high-technology AAC devices for adults with post-stroke aphasia was published by Russo and colleagues in 2017. The review included 30 publications and included a total of 250 individuals with acquired non-progressive post-stroke aphasia. Study sample sizes ranged from 1 to 10.  AAC included computer software (n=20), dedicated AAC devices (n=6) and software applications for tablets and/or smart phones (n=4).  A total of 16 studies showed positive outcomes, 11 studies reported mixed outcomes and 3 studies did not demonstrate improvement in communication.  Study findings were not pooled due to heteterogeneity of interventions and outcome measures.

Limitations of the literature includes the small size of studies, lack of comparison groups, and the small amount of research on any particular intervention.

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. 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.
  2. Ganz JB, Morin KL, Foster MJ et al. High-technology augmentative and alternative communication for individuals with intellectual and developmental disabilities and complex communication needs: a meta-analysis. Augment Altern Comm. 2017; 33:224-238.
  3. 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.
  4. Ganz JB, Mason RA, Goodwyn FD, et al. Interaction of participant characteristics and type of AAC with individuals with ASD: a meta-analysis. Am J Intellect Dev Disabil. 2014; 119(6):516-535.
  5. Ganz JB, Rispoli MJ, Mason RA, Hong ER. Moderation of effects of AAC based on setting and types of aided AAC on outcome variables: an aggregate study of single-case research with individuals with ASD. Dev Neurorehabil. 2014; 17(3):184-192.
  6. Kasari C, Kaiser A, Goods K, et al. Communication interventions for minimally verbal children with autism: a sequential multiple assignment randomized trial. J Am Acad Child Adolesc Psychiatry. 2014; 53(6):635-646.
  7. 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.
  8. Russo MJ, Prodan V, Meda NN, et al. High-technology augmentive communication for adults with post-stroke aphasia: a systematic review. Expert Rev Med Dev 2017; 14:355-370.
  9. 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.
  10. 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.
  11. Whitmore AS, Romski MA, Sevcik RA. Early augmented language intervention for children with developmental delays: potential secondary motor outcomes. Augment Altern Commun. 2014; 30(3):200-212.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Centers for Medicare and Medicaid Services. National Coverage Determination: Electronic Speech Aids. NCD #50.2. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=237&ncdver=1&DocID=50.2&ncd_id=50.2&ncd_version=1&basket=ncd*3a%2450.2*3a%241*3a%24Electronic+Speech+Aids&bc=gAAAAAgAAAAAAA%3d%3d&. Accessed on May 17, 2018. 
  2. Centers for Medicare and Medicaid Services. National Coverage Determination: Speech Generating Devices. NCD #50.1. Effective July 29, 2015. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=274&ncdver=2&DocID=50.1&bc=gAAAAAgAAEAAAA%3D%3D&. Accessed on May 17, 2018.
Websites 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 May 17, 2018.

Index

Digital Speech
Speech Impairment
Synthesized Speech

History

Status

Date

Action

Revised

07/26/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. Revised MN statement criteria A.2. to define what is meant by ‘high’ and ‘low’ technology devices. Removed asterisks and associated text from MN statement. Updated Discussion/General Information, References and Websites sections.

 

05/02/2018

The document header wording updated from “Current Effective Date” to “Publish Date.”

Revised

08/03/2017

MPTAC review. Changed “tech” to “technology” in indication A.2. Updated References and Websites sections.

Reviewed

08/04/2016

MPTAC review. Updated References and Websites. Removed ICD-9 codes from Coding section. Updated formatting in Clinical Indications section.

Reviewed

08/06/2015

MPTAC review. Updated References and Websites.

Revised

08/14/2014

MPTAC review. Clarified medically necessary criterion regarding an evaluation by the physician and licensed speech language pathologist. Updated References and Websites.

Reviewed

08/08/2013

MPTAC review. Updated References. Added Websites for Additional Information section.

Revised

08/09/2012

MPTAC review. Clarified not medically necessary statement. Updated Coding, Discussion/General Information, and References.

 

01/01/2012

Updated Coding section with 01/01/2012 CPT changes.

Reviewed

08/18/2011

MPTAC review. Updated Coding and References.

Reviewed

08/19/2010

MPTAC review. Updated References.

Reviewed

08/27/2009

MPTAC review. Removed Place of Service Section.

Reviewed

08/28/2008

MPTAC 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.

Reviewed

08/23/2007

MPTAC review. Formatting corrected in medical necessity section. Updated definitions and references.

Reviewed

09/14/2006

MPTAC review.

 

11/22/2005

Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).

Reviewed

09/22/2005

MPTAC 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.220 Speech Generating Devices
Anthem BCBS

10/01/2004

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

07/14/2005

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