Medical Policy



Subject: Altered Auditory Feedback (AAF) Devices for the Treatment of Stuttering
Document #: DME.00030 Current Effective Date:    09/27/2017
Status: Reviewed Last Review Date:    08/03/2017

Description/Scope

This document addresses the use of AAF devices for the treatment of stuttering.

Position Statement

Investigational and Not Medically Necessary:

Altered auditory feedback (AAF) devices are considered investigational and not medically necessary for the treatment of stuttering.

Rationale

Traditional treatments for developmental stuttering have involved various speech therapy techniques. In some cases pharmacologic therapy has been used. AAF has been investigated as a potential therapy. The rationale for AAF rests in the observation that individuals who stutter tend to become more fluent when speaking in unison with others – the so-called "choral effect." AAF attempts to emulate the choral effect by allowing the user to hear one's own voice with a slight time delay or a pitch shift which is said to create the illusion of another individual speaking at the same time.

The published literature on the clinical use and effectiveness of these devices consists of a few reports with small numbers of individuals. Lincoln and colleagues (2010) reported on 11 adults who used an AAF device to participate in speaking sessions with an investigator. The speaking sessions included conversational speech and reading aloud. Results were highly individualized depending on the condition. All participants responded differently under differing conditions to different AAF settings. The authors of this study concluded that it is not possible to predict who would benefit from AAF devices nor is it possible to predict the extent of any proposed benefit. The results are somewhat mixed and there is minimal data on its effect on everyday social fluency.

Gallop and colleagues (2012) reported on 7 individuals who stutter and used an AAF device. The study was designed to examine the long-term effectiveness of the device. The length of follow-up was 13 to 59 months. All participants were interviewed via telephone for approximately 30 minutes (15 minutes wearing the device and 15 minutes without the device). The authors found that time did not have a significant effect on stuttering frequency. This study is limited by the lack of a control group and the small sample size.

A study by Foundas and colleagues (2013) reported on 14 individuals who stutter and used the SpeechEasy® device, and compared them to a control group of 10 individuals. For those who used the device, device settings, ear placement, speaking task and cognitive variables were examined. When compared to the control group, the intervention group of individuals showed a greater reduction in stuttering compared to baseline while using the device with custom settings. Study groups remain small and there is little if any data on the long-term use of these devices, and no data to support that fluency would persist following discontinuation of the device. Larger prospective randomized controlled studies are required to demonstrate the effectiveness of AAF for everyday communication and fluency compared both to no treatment and to other forms of established therapy.

Ritto and colleagues (2016) conducted a randomized clinical trial that compared the effectiveness of an AAF device (SpeechEasy® , Janus Development Group, Greenville, NC) versus behavioral techniques in the treatment of stuttering. A total of 18 adults without hearing problems and who stutter were separated into two groups. Group 1 included 11 adults (10 men and 1 woman) aged 21-42 years (mean=30.0). Group 2 consisted of 7 adults (6 men and 1 woman) aged 20-50 years (mean=35.6). Both groups completed a baseline testing prior to treatment. The individuals in Group 1 were instructed to use the SpeechEasy device for 6 months without any training of fluency enhancing techniques. The participants in Group 2 were provided a 12-week fluency treatment protocol. Both groups demonstrated approximately 40% reduction in the number of stuttered syllables compared to baseline measures. The 3- and 6 month test times showed no significant differences between stuttered syllables (p>0.05). The authors concluded the following:

The results obtained with this study pointed future directions for our research, emphasizing the need to assess naturalness of speech and quality of life after both treatments modalities and, finally, provide a treatment combining AAF and therapy and compare the results obtained in this group with the results in this paper.

Background/Overview

Stuttering is a disturbance in the normal fluency and time patterning of speech that is inappropriate for the person's age. Developmental stuttering is the most common form, with an onset prior to the age of 12, and generally between the ages of 2 and 5 years. Preschool children normally undergo a transient period of disfluency, and it is estimated that 50%-80% of children with developmental stuttering will recover with or without therapy and generally before puberty. Persistent developmental stuttering is developmental stuttering that has not undergone spontaneous or therapy-related remission. Proposed etiologies include abnormal cerebral dominance with differences in regional brain activation patterns in regions of the brain that modulate verbalization. A genetic component has also been observed. Acquired stuttering in a previously fluent individual is much rarer than developmental stuttering, and may be neurogenic resulting from brain damage associated with conditions such as traumatic brain injury, Alzheimer's disease, and Parkinson's disease, among others. Psychogenic stuttering is also recognized following emotional trauma.

AAF devices use auditory feedback via an earpiece worn in or behind the ear, and utilize, alone or in combination, the following techniques: Delayed Auditory Feedback (DAF), delaying the user's voice to his ears a fraction of a second (this delay is adjustable) and frequency shifting auditory feedback or Frequency Altered Feedback (FAF) which shifts the pitch of the user's voice in his ears.

Definitions

Stuttering: A disturbance in the normal fluency and time patterning of speech that is inappropriate for the person's age.

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.

When Services are Investigational and Not Medically Necessary:
When the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

HCPCS  
E1399 Durable medical equipment, miscellaneous [specified as altered auditory feedback device]
   
ICD-10 Diagnosis  
F80.81 Childhood onset fluency disorder
F98.5 Adult onset fluency disorder
I69.023 Fluency disorder following nontraumatic subarachnoid hemorrhage
I69.123 Fluency disorder following nontraumatic intracerebral hemorrhage
I69.223 Fluency disorder following other nontraumatic intracranial hemorrhage
I69.323 Fluency disorder following cerebral infarction
I69.823 Fluency disorder following other cerebrovascular disease
I69.923 Fluency disorder following unspecified cerebrovascular disease
R47.82 Fluency disorder in conditions classified elsewhere
   
References 

Peer Reviewed Publications:

  1. Armson, J, Stuart A. Effect of extended exposure to frequency altered feedback on stuttering during reading and monologue. Journal of Speech Language Hearing Research 1998; 41(3):479-490.
  2. Costa D, Kroll R. Stuttering: An update for physicians. CMAJ. 2000; 162(13):1849-1855.
  3. Foundas AL, Mock JR, Corey DM, et al. The SpeechEasy device in stuttering and nonstuttering adults: fluency effects while speaking and reading. Brain Lang. 2013; 126(2):141-150.
  4. Gallop RF, Runyan CM. Long-term effectiveness of the SpeechEasy fluency-enhancement device. J Fluency Disord. 2012; 37(4):334-343.
  5. Hargrave S, Kalinowski J, Stuart A, et al. Effect of frequency-altered feedback on stuttering frequency at normal and fast speech rates. J Speech Hear Res. 1994; 37(6):1313-1319.
  6. Lincoln M, Packman A, Onslow M, Jones M. An experimental investigation of the effect of altered auditory feedback on the conversational speech of adults who stutter. J Speech Lang Hear Res. 2010; 53(5):1122-1131.
  7. Ritto AP, Juste FS, Stuart A, et al. Randomized clinical trial: the use of SpeechEasy® in stuttering treatment. Int J Lang Commun Disord. 2016;51(6):769-774.
  8. Stuart A. Investigations of the impact of altered auditory feedback in-the-ear devices on the speech of people who stutter: initial fitting and four month follow up. Int J Lang Communication Dis. 2004; 39(1):93-113.
  9. Van Borsel J. Delayed auditory feedback in the treatment of stuttering: clients as consumers. Int J Lang Communication Dis. 2003; 38(2):119-129.
Websites for Additional Information
  1. American Speech-Language-Hearing Association (ASHA). Stuttering. Available at: http://www.asha.org/public/speech/disorders/stuttering/. Accessed on June 14, 2017.
  2. American Speech-Language-Hearing Association (ASHA). Childhood Fluency Disorders. Available at:  http://www.asha.org/Practice-Portal/Clinical-Topics/Childhood-Fluency-Disorders/. Accessed on June 14, 2017.
  3. National Institutes for Health. National Institute on Deafness and Other Communication Disorders (NIDCD). Stuttering. 2017. Available at: https://www.nidcd.nih.gov/health/stuttering . Accessed on September 22, 2017.
  4. National Library of Medicine. Medical Encyclopedia. Stuttering. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/001427.htm. Accessed on June 14, 2017.
Index

Basic Fluency System
Disfluency
SmallTalk
SpeechEasy®

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Document History
Status Date Action
Reviewed 08/03/2017 Medical Policy & Technology Assessment Committee (MPTAC) review Updated Rationale, References and Websites sections.
Reviewed 08/04/2016 MPTAC review. Websites updated. Removed ICD-9 codes from Coding section.
Reviewed 08/06/2015 MPTAC review. Updated References.
Reviewed 08/14/2014 MPTAC review. Updated Rationale and References.
Reviewed 08/08/2013 MPTAC review. Updated Rationale, References, and Index.
Reviewed 08/09/2012 MPTAC review. Updated Index.
Reviewed 08/18/2011 MPTAC review. Updated Rationale and References.
Reviewed 08/19/2010 MPTAC review. Updated Rationale. Updated Coding section with 10/01/2010 ICD-9-CM changes.
Reviewed 08/27/2009 MPTAC review.
Reviewed 08/28/2008 MPTAC review.
  02/21/2008 The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.
Reviewed 08/23/2007 MPTAC review. Updated Index section statement.
Reviewed 09/14/2006 MPTAC review.
Revised 09/22/2005 MPTAC review. Revisions based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. 
Pre-Merger Organizations Last Review Date Document Number Title
Anthem, Inc.   None  
WellPoint Health Networks, Inc. 06/29/2004 9.03.04 Altered Auditory Feedback (AAF) Devices for the Treatment of Stuttering