Details:

Medicare is the nation’s largest health insurance program, giving coverage to people aged 65 years or older, disabled people receiving Social Security Disability Insurance (SSDI), and people with End-Stage Renal Disease (permanent kidney failure treated with dialysis or a transplant).

Medicare refers to AAC devices as “Speech Generating Devices”, or SGDs. Medicare classifies SGDs as “durable medical equipment”, and they are available to Medicare beneficiaries when the following four (4) criteria are met:

1) The beneficiary is enrolled in Medicare Part B

2) The beneficiary lives in his/her family home, or an assisted living facility (but not in a hospital, skilled nursing facility, or hospice)

3) The beneficiary is determined, following an assessment by a speech-language pathologist, to require an SGD to meet daily functional communication needs

4) The beneficiary's physician prescribes the SGD

 A speech generating device (E2500, E2508 - E2511, E2502 - E2506) is covered when all of the following criteria (1-7) are met:

1. Prior to the delivery of the SGD, the patient has had a formal evaluation of their cognitive and communication abilities by a speech-language pathologist (SLP). The formal, written evaluation must include, at a minimum, 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 a treatment plan that includes a training schedule for the selected device;

   6. The cognitive and physical abilities to effectively use the selected device and any accessories to communicate;

   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; and,

6. A copy of the SLP's written evaluation and recommendation have been forwarded to the patient's treating physician prior to ordering the device; and,

7. The SLP performing the patient evaluation may not be an employee of or have a financial relationship with the supplier of the SGD.

If one or more of the SGD coverage criteria 1-7 is not met, the SGD will be denied as not medically necessary.

Codes E2500, E2508 - E2511, and E2502 - E2506 perform the same essential function - speech generation. Therefore, claims for more than one SGD will be denied as not medically necessary.

Medicare requires that a speech-language pathologist (SLP) conduct, write, and sign the recommendations for specific AAC equipment and forward it to your physician for the agreement of medical necessity.

There is a particular way SLPs should conduct the evaluation. Medicare created a SGD Assessment Protocol as a guide so that speech language pathologists will conduct complete assessments and prepare written reports that address all of the points identified in the RMRP. 

Medicare utilizes one of four (4) Durable Medical Equipment Regional Carrier (DMERC) to process their claims.