ACTION POINT

 

SGD Recommendations to Health Based Funding Programs Must be for Dedicated Devices

When making recommendations for SGDs to be submitted for funding to any health based system of benefits, SLPs must pay close attention to the SGD model being requested. In every case, the model requested should be the dedicated or Medicare compliant version of the SGD recommended. There should be no exceptions. Making sure this occurs will not add any time to the SLP’s evaluation or report writing task: it should be the SGD model chosen for every recommendation. 

 

The reason for this alert is that recommending and submitting a funding request to a health-based funding program for an open or unlocked SGD model is an invitation to a funding denial. If that occurs, at a minimum the effect will be delay in the client’s access to and ability to benefit from the SGD. And, it will cause more work for the SLP and for the manufacturer as an appeal is pursued, or the process started over with a new recommendation. All of the foregoing also is wholly preventable, a self-inflicted injury. 

Most health based funding programs cover SGDs as items of durable medical equipment. The most common definition of DME includes the following 2 criteria:

• the item primarily and customarily is used for a medical purpose; and

• the item generally is not useful to an individual in the absence of illness or injury. 

Among the larger SGD manufacturers, e.g., Dynavox, PRC, Tobii, Words-Plus, their  “locked” or “Medicare compliant” SGD models will satisfy these criteria and their web pages likely state that their SGDs have been covered and paid for by Medicare. However, some of the manufacturers’ web pages prominently advertise the features of their “open” or “unlocked” models, which include many non-speech generating functions, such as internet access, e-mail, telephone capabilities, word processing, etc.   These devices are marketed SGDs that also can serve as fully functional computers.

 

While the manufacturers believe presenting this information will increase interest in their products, it is not the only effect.  Funding source staff also look at web pages. They do so not for education, but to find information that will support denial decisions. Consider the following response from United Healthcare, one of the nation’s largest insurers:

 

The request is for a Dynavox V which, according to the company website, is a full Windows XP computer that delivers internet access, email, text messaging and environmental control capabilities. This is in addition to being an augmented communicator [sic]. The Plan document provides coverage for durable medical equipment when it meets certain criteria, including that it be used for medical purposes and not be of use to a person in the absence of a disease or disability. This device is used as a personal computer as well as a communication device. Therefore, it does not meet the criteria set forth in the benefit document to be considered durable medical equipment. The requested Dynavox V is not a covered benefit.

This was not an isolated decision. The same reviewer wrote the same excuse to deny at least three SGDs in the past two years. And neither this reviewer nor United Healthcare are the only ones to deny SGD requests claiming they do not meet a policy or plan’s DME definition.

 

Faced with such a denial, one of the first steps of the appeal process is to ensure it correctly refers to the device being requested.  The reviewer for the cases just mentioned, for example, looked only at the manufacturer’s web-page; he did not bother to look at the order sheet accompanying the funding requests. They noted the dedicated version of the Dynavox SGDs had been requested, making it easy to point out the error in the denial, and to get the decisions reversed.

 

SLPs should have no trouble complying with this instruction. Funding reports are not archives of every fact known about a client; they are advocacy documents prepared specifically to meet the requirements of the funding program for which it is being prepared. Consistent with that message, SLPs have been told for years that their reports should make no mention of any use of the SGD that is not related to speech generation.  By following this instruction, the SLP or appeals can state there is nothing in the record to show the client has any need for; intent to use; or actual use during a trial period of any non-speech generating functions of the device.  Focusing on features that are not relevant to the client’s expected experience with the device is not a rationale to deny it.  Particularly when these features are not even operable on the specific model the client requested.

 

There also should not be any push-back claiming a client will want to use the device for non-SGD purposes. Even when that is true, that fact does not belong in a funding report to a health based funding program. That program is only interested in the speech generating uses of the device; that is the only reason it will be medically necessary. 

 

If students in school or adults want to have the device “open” to support other uses – e.g., other programs; e-mail; etc. – they can address “unlocking” these devices with the manufacturer after approval is issued by the funding source. The charge to unlock a device is minimal; the amount can be paid by a third party, e.g., a school; the amount can be negotiated with the company; and if it is a burden, the charge can be waived all together if the manufacturer wishes. The actual process to unlock the device is simple.  Compared to the risk that an “unlocked” or “open” device request will not be approved at all (est. value: $ 8,000), an unlocking charge (est. cost: $ 50) to make the device do all the client may want of it is not significant. 

 

In short: SLPs should not recommend open or unlocked devices. SLPs who do not heed this alert should expect the manufacturer either to return a funding request to have the SLP change the recommendation to the “locked” model; or expect the manufacturer will change the request itself when it submits the prior authorization request to the funding source.  

 

Speech Generating Devices are Items of “Durable Medical Equipment” (DME) Introduction

Speech Generating Devices (SGDs) are routinely covered by all health-benefits funding programs in the United States. This includes Medicare, all Medicaid programs, Tricare, the Veterans Administration, and more than 1,000 insurers and health benefits plans. This coverage exists even though SGDs (and as a general matter, other specific types of care or items of equipment) are only rarely identified by name by these programs. Instead, health benefits programs describe their scope of coverage by reference to broad categories of care, examples of which include in-patient hospital care; physicians’ services; speech-language pathology services; durable medical equipment; and prosthetic devices.

To determine what specific types of care and equipment are subject to payment by these health-based funding programs, a four-question “test” is applied. It asks:

1. Is the person a beneficiary, participant, or recipient of the benefits or funding program?

2. Does the type of care or item of equipment the recipient seeks “covered” within one or more of the benefits categories of the program?

3. Is the type of care or item of equipment the recipient seeks “medically necessary?” And

4. Is the type of care or item of equipment the recipient seeks subject to any limitations or exclusions? An obligation to pay for requested care or equipment will arise if each of the first three of these questions is answered “yes,” and the last question is answered “no.”

This memorandum explains why Speech Generating Devices (SGDs) are “covered” as items of “durable medical equipment” (DME), i.e., that they “fit” all the typical characteristics of DME items and “meet” the most common definition of DME used by health-based funding sources. The DME benefit category is the focus of this memorandum because SGDs are most often covered as DME; the second most common benefits category in which SGDs are covered is “prosthetic devices.” Both are very common covered benefits categories within health benefits programs. The programs that cover SGDs and their SGD coverage designation are listed Table 1.

Any SLP with questions about this issue should contact Lewis Golinker, at lgolinker@aol.com