Who will pay for the AAC Device? Once it has been ascertained that a client (child or adult) will benefit from AAC services, and a proper device as been identified, the matter of it’s cost becomes a leading issue. This was not the case in the selection of the device. In that process, the matching of the correct device to the user’s needs was the primary concern. But in most cases, the cost of the selected device exceeds the user’s ability to pay. There are, however, a number of funding sources that can be explored by the AAC Team, led typically by the Speech Pathologist. The hierarchy of sources includes the following: Private Purchase; CCS and MediCal; CCS alone; MediCal alone; Private Insurance; Low Incidence Education Funds; and General Education Funds, and many philanthropic organizations.

1. Private Purchase: When feasible, there are important advantages to be gained if the device can be purchased directly by the client or his/her caretakers using their own funds.

a. The Time Advantage: In a private purchase, the process, and hence the time it takes to actually procure the device, can be significantly shortened. This reduced time can be a critical issue, for example, in the case of ASL patients where the need for the device is great and immediate but frequently short lived; or in the case of young children where every day without the device may result in a significant loss of opportunity to learn basic communication skills.

b. The Ownership Advantage: Additionally, when users purchase their own device, it is clearly their property and can go with them when they move. This is not the case when the funding comes through the schools, for example, who then have the say as to when the device can be taken off campus (for example home after school); and to whom the device must be returned if the child moves out of the District.

c. The Accessories Advantage: There are many desirable features associated with AAC devices that may be excluded by many insurance sources, but which can be included if the device is privately purchased. For example, word processing and similar applications, access to the Internet, and many games are not allowed by many insurance programs but can be purchased privately.

2. California Children Services (CCS) and MediCal, for Children in need of an AAC Device: When the AAC funding for a child is dependent upon various government or private agencies, the organization of choice is a combination of CCS and MediCal.

a. MediCal is California's version the Medicaid program. This is a public health insurance program which provides needed health care services for low-income individuals including families with children, seniors, persons with disabilities, foster care, pregnant women, and low income people with specific diseases such as tuberculosis, breast cancer or HIV/AIDS. MediCal is financed equally by the State and Federal governments.

For Clients to be eligible to apply for MediCal funding, they must first be receiving services from a Regional Center. In this regard, it is important to get the name/number of the Regional Center Case Manager. This information can usually be obtained from the client’s parents or caretakers. If MediCal Insurance has not yet been secured, it will be necessary to ask the Regional Center Case Manager to apply for Medical Insurance for the client through Institutional Deeming with parent approval.

To be eligible for MediCal Insurance, the client must have more than one handicapping condition (viz., motor, cognitive and sensory); and must be receiving a minimum of two services from the Regional Center. A person over 18 years would also be eligible. In all cases the SGD must be accepted as being medically necessary. To be eligible for a device, the client must have a doctor’s prescription and an evaluation by a Speech Pathologist.

A medically necessary need is one in which the client cannot meet daily communication needs through other means (vis., oral speech or no or low tech AAC interventions); and one in which the SGD has been determined to be the most appropriate means of meeting daily functional communication goals. MediCal will help to finance doctors services, physical and occupational therapies and medical equipment. AAC devices are included as DME (durable medical equipment). This also includes repairs and replacement of Devices although typically there is a five year hiatus for replacing devices. This must certainly be taken into consideration by the SLP when selecting a device that may need to meet the developing communication needs of a child’s over five years; or the decline in communication abilities associated with degenerative pathologies.

If a client does not qualify for CCS, then MediCal may finance the AAC directly.

b. CCS is a Statewide program managed by the California Department of Health Services. It is funded by State, County and Federal tax monies; and some fees paid by the parents.

To be eligible for CCS funding, a child must be under 21 and have a physically disabling condition such as cerebral palsy, muscular dystrophy or some other medical condition which requires medical, surgical or rehabilitative services. The adjusted gross income of the parents must be, at least at the present, under $40,000, or if the medical expenses must come to more than 20% of the family income. To be eligible for a device, the client must have a doctor’s prescription and an evaluation by a Speech Pathologist.

CCS will pay for the evaluation to determine whether or not a child is eligible for their services, which include among others, doctors services, physical and occupational therapies and medical equipment. AAC devices are included as DME (durable medical equipment). As with MediCal, This includes purchase, repairs and replacement of devices, although typically there is a five year hiatus for replacing devices. This must certainly be taken into consideration when selecting a device that may need to meet the potential of a child’s development over five years; or the decline

If a client is not eligible for MediCal, then CCS may directly fund the AAC device.

c. The Process of applying for CCS /MediCal Funding begins with determining the status of the client with CCS and MediCal.

If a CCS status has not yet been determined, then it may be necessary to have the parents apply for CCS Services. As was mentioned earlier, CCS will pay for an evaluation. If, on the other hand, the client’s status has become inactive, it may be necessary (with the parents permission) to schedule an evaluation with CCS to activate the status. If the status with CCS is at a Consultation level, or active with a CCS Medical Therapy Unit (MTU), then it is necessary to obtain the name and number of the Occupational Therapist, and the name and number of the Supervising Occupational Therapist for the MTU.

If the MediCal status has not yet been determined (i.e., the client has no MediCal Insurance), the parents should be advised about the benefits of applying to MediCal. Of course this depends on the clients status with the Regional Center. If the client is receiving services from the Regional Center we will need to get the Name and Number of the Case Manager. It will be this Case Manager who will file the application for MediCal through a process called Institutional Deeming with parent approval.

If the MediCal application is in process, then we will proceed with the required device funding evaluation (i.e., using the CCS/MediCare Guidelines.) If or when the Client has an active status with MediCal, they will be assigned an Active Medical Number. The next step will be to conduct a CCS/MediCal device funding evaluation. If the client’s status with CCS is active, it is advisable to involve the CCS OT in the evaluation and trials. We should take care to follow the CCS/MediCal AAC device funding process, and provide CCS with an Evaluation Packet.

The AAC Evaluation Packet includes the following items:

a. The Completed AAC Device Evaluation Report in Medicare Format.

b. The Primary Physician’s Prescription for the device and peripherals.

c. A Price Quote from a vendorized DME Device Company delineating all equipment needs/current prices and not more than 30 days old.

d. If the Client has a Primary Insurance Carrier, a letter of denial for funding will be included.

3. MediCal only for funding Children in need of an AAC Device: Clients who do not have a diagnosis that is eligible for CCS (such as Downs Syndrome, Autism or Pervasive Developmental Disorder, etc.) may be funded directly from MediCal if they are qualified. It must first be ascertained, however, whether or not the AAC device can be funded by the client’s Private Primary Health Insurance Provider. This involves contacting the clients Primary Health Physician to inform him/her of the evaluation. The Physician should then be provided with the evaluation and the specifics for the prescription based on the evaluation. The Evaluation Report; the prescription, and the Device costs quote must be submitted and reviewed by the Primary Health Insurance Carrier (usually by the Durable Medical Equipment (DME) Department). If the request for funding is approved, then the AAC device will be procured by the Private Insurance Company. If not then a letter of denial must be provided to the SLP. Then the Evaluation Packet (including the AAC Evaluation Report: the Primary Physician’s prescription, the Denial letter from the Private Health Insurance Company; and the Price Quotes is sent to the Funding Department of the Device Vendor (who must have a DME Vender Number) for MediCal.

CCS only for funding Children in need of an AAC Device: For children who are active or who qualify for CCS but are not eligible for MediCal, the funding my be provided by CCS alone. The CCS status must first be determined. Plus to be eligible for device funding the yearly income of the parents must be below $40,000 a year. If the child is equipment eligible under CCS then the AAC Device Evaluation should be undertaken. The CCS OT should be notified and involved in the evaluation process. The completed Evaluation Packet should then be submitted to CCS.

4. Private Insurance funding for Children in need of an AAC Device: It must first be determined whether or not the Insurance Policy covers Speech/Language, and Durable Medical Equipment. Even so, it must also be checked to see that there is no exclusion clause specifically for AAC Devices. An AAC Device Evaluation following Medicare Guidelines can then be conducted. A copy of the report should be sent to the Primary Physician including the specifics for a prescription. The Physician should then submit the funding materials to the DME Department of the Insurance Company with a 30 day response request. It is important to keep touch with the parents and the Physician until a decision by the insurance company is made. If the funding request is denied, but the insurance does cover Speech/Language and DME, then the objections should be ascertained and addressed and the funding request re-submitted.

5. Low Incidence Public School funding for Children in need of an AAC or AT Device: A child who has a low incidence disability, as described by the State Department of Education, which includes severe orthopedic impairments (such as cerebral palsy,) or multiple motor, speech and sensory impairments; but who is NOT eligible for CCS, MediCal or Private Insurance services, my apply for funding through the Department of Education. It is important in this case that the IEP Team write goals and objectives that include the use of an AAC (or AT) device. The next step is for the AAC Specialist and the Case Manager to complete the Low Incidence Form and submit it along with the EIP report to the appropriate school Program Administrator for review. If approved, the low incidence equipment is logged into the low incidence database and the AAC Specialist and/or the Case Manager is contacted. When procured, the equipment is the property of the school and will be retained by the School if the Child moves out of the jurisdiction of the California State Department of Education. The school authorities also determine whether or when the child can remove the AAC device from the school premises (for example to take it home after school).

6. General Education Public School funding for AT or AAC Equipment Budget: If a student does not qualify for low incidence funding, nor CCS or MediCal, and Private Insurance is not an option, General Education funding is a possibility. To access this funding, the client must have an AAC device assessment conducted in accordance with the Medicare guidelines. The IEP Team must write goals/objectives, which include the use of AAC or AT. The AAC/AT Specialist and the Case Manager will complete an Equipment Requisition and send it along with the IEP to the appropriate Program Administrator for review/approval. If approved the AAC/AT equipment is logged into the equipment database and the AAC Specialist/Case manager is contacted to obtain the equipment.

7. Tricare funding for AT or AAC Equipment Budget: Tricare is the Insurance Carrier for Personnel on Active duty, and their dependents. The process for applying for Tricare funding is the same as applying to any Private Insurance Company. Medicare guidelines should be followed in the assessment process.

8. Medicare funding for AT or AAC Equipment Budget: Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over, or who meet other special criteria. Medicare operates as a single-payer health care system. Single-payer health insurance collects all medical fees and then pays for all services through a single government (or government-related) source. To obtain Medicare funding, you obtain the aid of the Funding Coordinator of the Company Manufacturing the Device. If the device is accepted for funding, there is a 20% copayment required from the patient.

9. Department of Rehabilitation funding for AT or AAC Equipment: When students are 18 years and over, the Department of Rehabilitation Counselor should be contacted to ascertain the possibility of obtaining an AAC/AT device that would enable the client to achieve a vocational goal.

10. Other Organization often accessible for AT or AAC Equipment: Despite the major funding sources mentioned above, there are a number of other smaller organizations that are possible funding sources. These include but are not limited to:

a. Disability Organizations that include groups like Easter Seals, United Cerebral Palsy Association, the March of Dimes, the Braille Institute, and Crippled Children's Services (CCS).

b. Service Organizations: Included here are groups like United Way, Lions Club, Masonic Order, Elks Club, Rotary Club, Kiwanis Club and the Veterans of Foreign Wars (VFW). In this last case, the children of veterans may be eligible for receive assistance.

c. Private Organizations: Various companies in Private Industry, Special Education Parent Organizations, Church groups and the PTA have also provided funding for AT.

APPENDIX A

Speech Language Pathology Evaluation Report Form Examples

=============================================================

1 Example by Words +

Words+, Inc. 1

Speech Evaluation Form

I. Demographic Information

Patient Name: Client Advocate:

Address: Phone #:

DOB: Medicare/Medicaid ID#:

Primary Diagnosis: ICD-9: Onset:

Secondary Diagnosis: ICD-9: Onset:

Speech Language Pathologist Name: Phone #:

Address: Email Address

Date of Evaluation:

Physician Name and Address:

Phone #: Fax #

NPI# License #

II. Current Communication Impairment

A. General Statement of Patient’s condition-diagnosis: List medications, if applicable

____________________________________________________________________

1. Type of Communication impairment: Check all that applies

Dysarthria

Aphasia

Apraxia

Aphonia

2. Severity of impairment: List impairment checked above with the corresponding severity

Mild

Mild-Moderate

Moderate

Moderate-Severe

Severe

3. Anticipated Course of Impairment: Check which applies No

detectible Speech Disorder

Obvious Speech Disorder, intelligble

Reduction in speech intelligibly

Natural Speech supplemeted with SGD's

No useful Speech (SGD only)

Loss of Speech

B. Comprehensive Assessment

1. Hearing Status

Does the patient possess the hearing ability to effectively use a SGD

to communicate functionally? Yes ________ No________

Does the client use a hearing aid? Yes_______ No________

2. Vision Status

Does the patient possess the visual ability to effectively use SGD to communicate effectively? Yes_______ No_______

Does the client wear prescribed eyeglasses? Yes_______ No________

3. Physical Status

Does the patient possess the physical ability to effectively use a SGD and required accessories to communicate? Yes _______ No _______

Comments

Motor Skills

Ambulatory Status

Direct Selection

Scanning

4. Language Skills

Linguistic Impairment Severity: Check which applies Mild

Mild-Moderate

Moderate

Moderate-Severe

Severe

Assessment tools/tests used in evaluation:

Assessment test

Evaluation

Current communication ability: Check which applies

Sign Language

Gestures

Pictures

Words

Writing/Spelling

Verbal Speech

5. Cognitive Ability

Impairment Level: Check which applies

No Impairment

Mild Impairment

Moderate Impairment

Significant Impairment

Abilities with an SGD: Check which applies

Poor	Fair	Good	Excellent
Memory
Attention
Problem Solving Skills

Comments:___________________________________________

____________________________________________________

III. Daily Communication Needs

1. Specific Communication Needs:

a. Client interacts daily with: Check all that applies

Family __________

Caretaker __________

Health Care Professionals __________

Community __________

b. Clients needs: Check which applies

Request Emergency Aid ___________

Obtain Medical Care ___________

Advocate for him/herself __________

Express pain/reaction to medication __________

Express hunger/thirst __________

Express likes/dislikes __________

Additional Needs: ___________________________________________

__________________________________________________________

2. Ability to meet communication needs with Non-SGD treatment:

a. Speech Therapy

Date Began _____________ Date Ended:___________

Current Prognosis without a SGD: Check which applies

Poor ______

Fair ______

Good ______

Excellent ______

Future Prognosis without a SGD: Check which applies

Poor ______

Fair ______

Good ______

Excellent ______

b. Low Tech Strategies used during therapy sessions:

_________________________________________________________

Results of Low Tech Strategies: Check which applies

Poor ______

Fair ______

Good ______

Excellent ______

Can the patients daily communication needs be met by low tech AAC or no-tech AAC technique? Yes _______ No________

IV. Functional Communication Goals: Level of communicative independence the patient is expected to achieve outside the therapeutic environment with an SGD.

Check all that apply:

_____ Client will independently communicate physical needs and emotional status to immediate family/caretaker on daily basis, as needed.

Expected length of time to achieve goal: Circle which applies

Immediate Short Term Long Term

_____ Client will describe her physical symptoms and ask any questions when interacting with his/her physician and other health care professionals.

Expected length of time to achieve goal: Circle which applies

Immediate Short Term Long Term

_____ Client will engage in social communication exchanges with immediate family and extended members in person and by use of the telephone.

Expected length of time to achieve goal: Circle which applies

Immediate Short Term Long Term

_____ Client will engage in social communication exchanges with friends at home and in other community settings.

Expected length of time to achieve goal: Circle which applies

Immediate Short Term Long Term

_____ Client will engage in decision making of his/her own personal affairs.

Expected length of time to achieve goal: Circle which applies

Immediate Short Term Long Term

V. Rationale for Device Selection

A. General Features of recommended SGD and accessories:

Input/output features

1. Direct Selection: Check all that apply to client

_______Keyboard access ability

_______Touch screen

_______Other, Please Specify

___________________________________________

2.Scanning:

A. Switch Access Capability:

_____Single _____Double _____Other, please specify

Comments: _________________________________________

_________________________________________

B. Method:

______ Linear ______ Row-Column ______Group

______ Other, Please specify

Comments: _________________________________________

_________________________________________

C. Ques:

_______ Auditory _______Visual

Comments: _________________________________________

_________________________________________

42505 10th St. West, Lancaster, CA 93534 Tel: 1-800-869-8521 Fax: 661-723-2114 Words+, Inc. 7

3.Symbols

_______Pictures ______Words/Phrases

_____Other, Please Specify

Comments: _________________________________________

_________________________________________

4. Other Features

a. Portability Access: Check which applies

Carrying Case ________

Wheelchair Mounting:__________

(Please provide name and manufacturer of wheelchair)

b. Battery time required-If Medicare is a payer, please use ABN form

Long life ______

Additional Battery_____

c. Misc. Please list all that are necessary-If Medicare is a payer please use

ABN form

Example: Environmental Control, Additional RAM, additional switch, additional mount or mount pieces, larger screen size, etc.

________________________________________________

B. Recommended Device and Accessories

The client’s ability to meet daily communication needs will benefit from an acquisition and use of the HCPCS category:

______ E2500= Speech Generating Device, digitized speech, suing pre- recorded messages, less than or equal to 8 minutes recording time. Mini Message Mate

______E2502= Speech generating Device, digitized speech, using pre- recorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time. Message Mate’s

______E2504= Speech generating device, digitized speech, using pre- recorded messages greater than 20 minutes but less than or equal to 40 minutes recording time.

______ E2506=Speech Generating device, digitized speech, using pre- recorded 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. Say-it! SAM Communicator V2

_______E2510=Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access. Freedom SGD, Say-it! Sam Tablet XP1 or SM1, Conversa, Freedom Lite Convertible,

Freedom Lite

_______Other please describe:________________________________

_________________________________________________

C. Trials with SGD’s

Device #1

Name of Device:

Features:

Client Success: circle all that apply

Poor Difficult Good Easy

Explain: ____________________________________________

____________________________________________

Device #2

Name of Device:

Features:

Client Success: circle all that apply

Poor Difficult Good Easy

Explain: ____________________________________________

____________________________________________

Device #3

Name of Device:

Features:

Client Success: circle all that apply

Poor Difficult Good Easy

Explain: ____________________________________________

____________________________________________

42505 10th ______ E2506=Speech Generating device, digitized speech, using pre- recorded 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. Say-it! SAM Communicator V2

Freedom Lite

_______Other please describe:________________________________

_________________________________________________

C. Trials with SGD’s

Device #1

Name of Device:

Features:

Client Success: circle all that apply

Poor Difficult Good Easy

Explain: ____________________________________________

____________________________________________

Device #2

Name of Device:

Features:

Client Success: circle all that apply

Poor Difficult Good Easy

Explain: ____________________________________________

____________________________________________

Device #3

Name of Device:

Features:

Client Success: circle all that apply

Poor Difficult Good Easy

Explain: ____________________________________________

____________________________________________

D. Specific Recommended Device

A. (Reference quote provided by Sales Representative, if applicable)

Name of Device:

Accessories:

Vendor:

E. Patient and Family Support of SGD

Please identify if the client and family members/caretakers are motivated and agree with the device selected.

________________________________________________________

F. Physician Involvement

A copy of this report was forwarded to the clients treating physician and he/she will generate a prescription for the recommended device and accessories.

VI. Treatment Plan

. The client will receive 4 hours of training with the local sales representative.

. The client will receive _______ therapy sessions with the Speech Language Pathologist once they receive the device.

VII. Signatures/SLP Assurance

The Speech Language Pathologist performing this evaluation is not an employee of and does not have a financial relationship with the manufacturer/supplier of the device.

_____________________________________

SLP Name

Words+, Inc. 42505 10th St. West, Lancaster, CA 93534 Tel: 1-800-869-8521 Fax: 661-723-2114 10 j

ASHA #

State License

=============================================================

2 Example by Zygo:

Example 70 YEAR OLD WOMAN WITH PROFOUND DYSARTHRIA SECONDARY TO ALS Facility Name Department of Speech-Language Pathology Facility Address and Phone Numbers MEDICARE FUNDING REQUEST FOR SPEECH GENERATING DEVICE (SGD)
I. DEMOGRAPHIC INFORMATION
Patient's Name: Date of Birth: Address:	Social Security #: Phone Numbers:
Patient's Primary Contact Person: Address:	Relationship to Patient: Phone Numbers:
Medical Diagnosis: Amyotrophic Lateral Sclerosis
Date of Onset: Date of Evaluation:	Date of Request:
Physician: Speech-Language Pathologist:	Phone Number: Phone Number:

II. CURRENT COMMUNICATION IMPAIRMENT

A. General Statements

Impairment Type & Severity (ICD-9 Diagnostic Code: 784.5)

Secondary to ALS, Mrs. _____ presents with a profound dysarthria and is functionally nonspeaking. Produces differentiated vowels with varying intonation. Imitates monosyllabic words, with referent known, with ____% intelligibility.

Oral motor control limited to gross movements only, and these movements are imprecise, reduced in range and executed slowly (e.g. open - close mouth, protrude tongue). Patient receives nutrition through gastrostomy tube. Spontaneous speech is limited to vocalizations.

Anticipated Course of Impairment
Based on the Severe Dysarthria due to Amyotrophic Lateral Sclerosis Staging Scale (a 5-point scale, with 1 being no detectable speech disorder and 5 being no useful speech), patient's speech is characteristic of Stage 5 - No useful speech. Given the patient's current status and progressive nature of ALS, it is anticipated that Mrs. ___'s condition will deteriorate further.

B. Comprehensive Assessment

Hearing

No problems with hearing noted or reported. Patient passes pure tone audiometric screening for octave frequencies at 25 dB from 500- 4000 Hz. Attends to and discriminates natural and synthetic speech at conversational loudness levels. Husband may have slight hearing loss, although his hearing has yet to be formally assessed. Husband successfully discriminated synthetic speech in SGD, at sentence level, given occasional repetition (of spoken message) and reliance on visual display. Patient and primary communication partner possess hearing abilities to effectively use SGD to communicate functionally.

Vision

Patient wears bifocal glasses at all times. Shows no problems with visual attention, scanning, tracking, or acuity with glasses on. Discriminates ¼" text on display positioned at midline, at a distance of approximately 18", without difficulty. Possesses visual abilities to effectively use SGD to communicate functionally.

Physical

The patient is wheelchair dependent. Has an electric wheelchair (Jazzy 1100, with a right joystick controller). Drives chair independently and safely. Seating tolerance approximates 2 -3 hours. Patient referred to physical therapist for recommendations to improve seating comfort and tolerance. Patient spends several hours/day in a standard recliner chair. Needs access to SGD from both wheelchair and recliner.

Patient reports weakness in both upper extremities. Patient is right hand dominant. Able to type on standard keyboard using middle right finger and left index finger. Types quickly and with few errors. No indications of fatigue or discomfort after typing several sentences. Does not require keyguard at this point in time. Accommodations may be required as ALS progresses (e.g. keyguard, scanning module/switch). Patient possesses the physical abilities to effectively use a SGD with noted accessories to communicate functionally.

Language Skills

Informal assessment reveals oral and written language skills within functional limits. Patient answers abstract yes/no questions with 100% accuracy and follows multistage directions with 100% accuracy. Answers multiple choice questions about a paragraph read silently with 100% accuracy. Types grammatically correct, syntactically complex sentences. Formulates meaningful written paragraphs independently.

Cognitive Skills

Patient retains task instructions without difficulty. Recalls 100% (5/5) of messages stored under abbreviations. Identifies logical codes to abbreviate messages. Spontaneously uses strategies to aid message production (e.g. abbreviates words) Consistently gives partner feedback (using SGD and nonverbal cues) to indicate if message is accurately interpreted. Corrects and clarifies messages as appropriate. Spontaneously and appropriately shifts between communication approaches to maximize communication efficiency. Demonstrates ability to use word prompting and prediction. Possesses cognitive/linguistic abilities to effectively use SGD to communicate and achieve functional goals.

III. DAILY COMMUNICATION NEEDS

A. Specific Daily Communication Needs

Primary communication situations involve 1:1 and small group situations. Primary environments are home and medical appointments. Primary communication partners include husband, daughter, friends, paid caregivers, and medical staff. Specific message needs include expressing needs, making requests, asking questions, offering information, and expressing feelings/opinions. Patient expresses strong desire to maintain her role as a decision maker in the home, to socialize with friends and family, and to communicate directly with medical staff regarding her disease and treatment.

B. Ability to Meet Communication Needs with Non-SGD Treatment

Patient has previously received speech maintenance therapy. However, given the current severity of the patient's speech impairment, coupled with the progressive nature of ALS, therapy to improve speech production is no longer indicated or appropriate.

The patient relies on yes/no responses, vocalizations, facial expressions, simple gestures (e.g. pointing to items in environment), alphabet board and desk top computer. Unaided approaches are effective for calling attention and indicating very basic needs (e.g. pointing to a cup to request drink).

The alphabet board is used to generate novel messages during face-to-face conversations with husband, daughter and a few close friends. The board is adequate for basic needs that require a 2 or 3 word message; messages exceeding 2-3 words are difficult for partner to decode/retain. The board also requires the partner to be standing beside the patient as she composes her message. This can be tedious and time consuming for all partners and is not tolerated by medical personnel. The board is ineffective in-group social situations, because not all partners can see the board and follow along as the patient spells. The board is not effective with hired caregivers because they cannot read English. The desktop computer is used to prepare messages in advance for either the husband or daughter. The computer is not portable nor does it have voice output.

The patient's current communication approaches do not permit her to convey the type and complexity of information in the environments and with those partners with whom she interacts on a daily (i.e. husband, daughter, care givers) or intermittent basis (i.e. physicians, friends).

IV. FUNCTIONAL COMMUNICATION GOALS

Upon receipt of an SGD, therapy will target the following goals. Ms.___(Patient) will:

Demonstrate ability to master basic maintenance and operations of SGD (on-off, adjusting menu features such as voice and display) with 100% accuracy (within 2 weeks)
Demonstrate ability to program stored messages independently with 100% accuracy (within 2 weeks)
Convey basic needs/make requests to caregivers, by spelling or retrieving pre-programmed message on SGD, independently and with 100% accuracy (within 2 weeks).
Initiate social greetings, offer information, ask questions, express feelings and opinions through spelling and retrieving stored messages on SGD, during 1:1 and group situations with familiar and unfamiliar partners, independently and with 100% accuracy (within 3 weeks).
Use strategies on SGD to expedite message production when sharing information or asking questions of medical personnel, independently and with 100% accuracy (within 3 weeks).

V. RATIONALE FOR DEVICE SELECTION

A. General Features of Recommended SGD and Accessories

Based on the above noted comprehensive assessment, daily communication needs, and functional communication goals, the patient requires SGD with the following features:

Input/Message Characteristic Features:

Direct selection with index and middle fingers of both hands/standard or mini keyboard (patient prefers QWERTY keyboard)
Flexibility to accommodate changes in physical access (i.e. alternative keyboard, scanning)
Accessible from multiple positions (i.e. wheelchair, Lazy Boy)
Alphabet based with multiple means of message formulation (i.e. abbreviation expansion, word prediction, and pre-stored message recall)

Output:

Text-to-speech speech synthesis (given that patient has novel message needs and is relying on spelling as primary means to generate messages)
Two-way visual display to aid husband (who has suspected hearing loss) to interpret messages
Capability to facilitate communication at a distance.

Other features:

Portable to accommodate conversational needs in various locations within home and at medical appointments
Long lasting battery to ensure device is operational in various locations and to minimize need to be close to electrical outlet.

B. Recommended Medicare Device Category and Accessories Codes

The individual's ability to meet daily communication needs will benefit from acquisition and use of the SGD Category E2510 and equipment that enable device to be mounted from SGD accessory code (E2512).

C. Trials with SGDs

Patient participated in trials with 3 SGDs in Category E2510 that have the input and output features similar to those delineated above. The SGDs included Spok21-Combi, the Allora, and the Polyana 4 with Persona. Both current and future communication needs were considered as her physical condition is likely to deteriorate.

Spok21. Patient had difficulty with remembering where stored messages were put.
Allora. After demonstration only used the Allora to generate novel messages. Used all function keys without difficulty. Given the scanning limitations, the inability to see the target during the complete scan cycle, and the small visual display the Allora is not an optimal solution.
Polyana 4 with Persona. The patient independently utilized the Polyana to communicate her needs. Spelled lengthy, complex messages without difficulty. Used word completion and word prediction with 100% accuracy and recalled all messages stored under abbreviation/expansion. The husband successfully interpreted all of the patient's messages relying on speech output and only once had to look at the visual display. The patient was shown scanning features and was able to select messages using row-column scanning.

D. Recommended SGD and Accessories

Based on comprehensive assessment and SGD trials, it is recommended that the patient be fitted with the Polyana 4 with Persona and wheelchair mount to secure the device and allow independent access. The recommended wheelchair mount is designed to accommodate the Polyana 4 and will enable her to use the device throughout most of the day.

Part Number	Description
Polyana 4 with Persona	Polyana 4 with Persona text-to-speech communication device
039-9089-55 MS-48	Medium weight mount, 3x1" chair clamp, 1x2’ tube, pin release, quick release tray
CM-40	Lolly Switch

Polyana and accessories are available from:

ZYGO Industries, Inc. 800 234-6006 or 503 684-6006 FAX 503 684-6011
P.O. Box 1008
Portland, OR 97207-1008

E. Patient and Family Support of SGD

The patient and her husband demonstrate motivation to maintain SGD. Have established basic skills with the Polyana. The patient understood the pros/cons of different devices and identified the Polyana as the optimal device for her needs.

F. Physician Involvement Statement

A copy of this report has been forwarded to the patient's treating physician (DR. … #XXX) on ______ (date) for review and prescription.

VI. TREATMENT PLAN

Upon receipt of SGD, it is recommend that the patient receive 45 minutes of individual therapy and one hour of group therapy weekly for 8 weeks (total 16 sessions). These sessions will address goals listed in Section IV of this report. An additional two hours of training are recommended to train caregivers to program the device.

V. SIGNATURES / SLP ASSURANCE OF FINANCIAL INDEPENDENCE

The Speech-Language Pathologist performing this evaluation is not an employee of and does not have a financial relationship with the supplier of the SGD.

____________________
XXX MS CCC-S
Speech Language Pathologist
ASHA #
State Lic.

GLOSSARY OF TERMS

Allowable The amount of money for which your insurance company will allow a claim to be processed. The client's co-insurance is usually based on their allowable amount. For example, if the allowable amount is $5,000.00, and the client's co-pay is 10%, the amount the client will owe is $500.00.

Assignment of Benefits (AOB) Form signed by the policy holder that allows the insurance company to pay ZYGO Industries, Inc. or its dealers directly. Without an AOB, the policy holder may receive the insurance payment.

Certificate of Medical Necessity (CMN) This is usually a state-specific form which is signed by the physician or speech therapist.

Claim Billing submitted to the insurance company after the equipment has been delivered.

Client Advocate Person who is representing the client during the funding process. This person is usually a speech therapist or case manager.

CPT Code The Current Procedural Terminology code describes the type of services that are being supplied. This is generally the same as a HCPC Code.

Custodial Care Facility Facility that provides room, board, and assistance with daily living activities, such as feeding and dressing. This care is generally on a long term basis and does not entail the continuing attention of trained medical personnel.

Deductible That amount that the client must pay annually before benefits will be paid by the insurance company.

Durable Medical Equipment (DME) Systems made to withstand repeated use that are used for the treatment of an injury or disease. Speech Generating Devices have been classified as Durable Medical Equipment.

Explanation of Benefits (EOB) The statement from the insurance company showing the services and amounts that were paid by the policy. This is also known as a remittance.

Exclusions Services for which the insurance company will not pay.

Funding Questionnaire (FQ) A questionnaire that is usually completed by a family member or other contact person which includes important information such as the client's address, physician, insurance information, and a list of the equipment that they wish to order.

HCPC Code that is used to describe the services rendered. For example, the Polyana with Persona has a Medicare HCPC code of E2510.

Hospice Supportive care given to a terminally ill client and their family. The focus of this care is to enable the client to remain in the familiar surrounding of their home for as long as they can. Hospice care may be either inpatient or outpatient.

ICD-9 Code International Classification of Diseases. Insurance code that describes a client's medical condition or diagnosis.

Insurance Letter of Requirement (ILR) This letter is sent to your insurance company by your funding coordinator and explains the details that should be included in a private insurance authorization. An approval form is also included with this letter. Insurance companies may complete the approval form instead of creating a letter.

Invoice Itemized statement explaining what items or services have been delivered.

Letter of Medical Necessity (LMN) A letter explaining the medical need for AAC services. This letter can be written by a physician, speech therapist, or occupational therapist. These letters usually give the client's diagnosis and a brief explanation of why services are necessary.

Maximum Out of Pocket The maximum amount a client will pay towards their deductible and co-insurance during the year.

Managed Care Organization (MCO) Any insurance plan in which the client will need to have services approved by their plan's referring physician or medical group.

Medicaid State-sponsored medical plan. Eligibility for these plans is traditionally based on a family's income. May also be called Title 19.

Medicare Federally-sponsored medical plan. Clients become eligible for this program when they turn age 65 or have a qualifying disability. There are two separate programs under Medicare Part A (hospitalization) and Part B (medical). Clients must pay a monthly fee for Part B coverage. speech generating devices are covered under Medicare Part B.

Medicare Supplement An insurance policy that covers Medicare co-payments and other services. This policy must be purchased by the Medicare beneficiary.

Non-Participating Provider Provider that has not contracted with a health insurance company to provide services at a reduced fee. Also referred to as an Out of Network Provider.

Original Documentation Prescription and speech evaluation that has an original signature. The signature page on the evaluation and the doctor's prescription cannot be stamped, copied, or faxed. Medicare requires that original documentation be on file with the vendor for any product.

Payment Agreement (PA) Form signed by a policy holder stating that they agree to cover any amounts not paid by the insurance company.

Place of Service (POS) The location where the medical services will be provided or used. It is important that we know whether a client lives at home, in a group home, or in a nursing facility. Some funding sources will not cover clients that live in a nursing facility.

Pre-certification See Prior Authorization.

Pre-determination A review done by an insurance company to determine whether a service will be considered a covered benefit.

Prior Authorization Approval issued by the insurance company before equipment is delivered. Authorizations are normally issued by nurse reviewers at the insurance company who review the doctor's orders and other documentation to ensure that a service is medically necessary.

Referral Specific directions or instructions from a client's primary care physician. Referrals may be on paper or electronic and are usually required by HMO policies.

Release of Information (ROI) A form that is signed by a client or their guardian and gives permission for the vendor to release medical documentation to insurance companies and other funding sources.

Remittance A statement sent to medical providers from the insurance company to show the payment that was issued. Also called Explanation of Benefits (EOB).

Rx Prescription. This must be signed by a medical doctor or dentist.

Sole Source Supplier A provider who is the only source for a particular service or type of equipment.

Subscriber The employee covered under an employer's group insurance policy. Also referred to as the policy holder.

Skilled Nursing Facility (SNF) A facility which provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but do not require the level of care provided in a hospital. If a person is in this type of facility, they are not able to use Medicare as a funding source.

Stop Loss See Maximum Out of Pocket.

UPIN Unique Physician Identification Number. Identification number that is used to identify the physician who signed the prescription. This number is used when filing claims to insurance companies.

Usual and Customary Charges Also referred to as Reasonable and Customary Charges. An amount determined by an insurance company that represents a routine charge for a medical service by similar medical and professional providers in the same geographical area. Allowable amounts are normally based on the Usual and Customary Charges.

========================================================================

EXAMPLE 3 EVALUATION BY PRC

AAC Evaluation for John Doe

Submission Type: Purchase

Date of Evaluation 5/30/2008

Date of Report 7/16/2008

Client Information

Name: John Doe Telephone: (330) 111-2222

Address: 123 Main St, N/A

Wooster, OH 44691 Place of Residence: Home

Medicaid ID Num.: 111111111 Date of Birth: 1/1/1998 Age: 10

Medicare ID Num.: N/A

Medical Diagnosis: Cerebral Palsy (343.9)

Insurance Policy Num.: XYX0000000000222 Onset: 1/1/1998

Referred By: James Smith

Speech Diagnosis: Aphasia (784.3)

Licensed SLP: Mary Bing Onset: N/A

Description of Impairment

Impairment Type, Severity

John is a 10 year old male diagnosed with Cerebral Palsy (343.9).

Briefly describe diagnostic assessment, results of formal and informal tests, speech intelligibility.

John is highly motivated to communication with a speech generating device. He recalls symbols locations, device operations and instructions.

He initiates communication spontaneously with his family, physician, nurses, and myself. He is able to spell.

Briefly describe current communication system and explain why it does/does not meet the client's current needs.

John currently uses a Pathfinder. The Pathfinder has older technology. It features a static display with 128 locations. John's vision has changed

and the icons are too small for him. Also, he has some lost motor control in his right arm and will need a more comprehensive access method.

Due to this loss of motor control, sign language is not an option.

/ X / Given the severity of the communication impairment as described above the Client's speech does not meet his/her daily communication needs.

/ X / Speech intelligibility in spontaneous communication is judged to be 95% unintelligible to the unfamiliar listener.

Anticipated Course of Impairment

The Client's condition is chronic and stable and independent communication is expected to remain stable at the present level. Therefore it is anticipated that the Client's natural speech will not be sufficient to meet daily communication needs for the client's lifespan. The prognosis for

speech production to meet communication needs is poor.

Hearing Status

History of hearing impairment: / / A history /X / No history

Client has: No other hearing issues

If the Client has a hearing loss, please specify the percentage: %

Modification to SGD

With the modification indicated below, the Client demonstrates adequate hearing ability to use a SGD to communicate functionally.

/X / No modifications needed

/ / Specify Speech: Synthesized

/ / Specific speech output options: (describe type of speech synthesizer, voice, digitized, loudness): John presents with no history of a hearing impairment, so volume is not an issue.

/ / Additional Comments: N/A

Visual Status

The Client has a history of mild uncorrected visual impairment. Informal observation of functional visual performance during the SGD assessment

revealed the Client required the modifications listed below to use a SGD effectively given current vision status.

Modification to SGD

/X / No modifications needed

/ / Client will respond to: Dynamic display

/ / Font size used on SGD display and/or symbol labels should be: Medium

/ / Picture-symbols and/or icons should be the following size (inches): .75 x .75

/ X / A flat display is required to reduce visual tracking requirements (e.g., need to alternate focus between keyboard and display to monitor

selections)

/ / If applicable, color contrasts are needed to enhance visibility of text or symbol on SGD.

/ / Number of items per display should be: 84

/ / Ability to hide keys is required to reduce visual distractibility.

/ / Auditory prompts from device are needed to assist in message preparation/selection.

/ / Additional Comments: N/A

Physical Abilities

Physical Status

The Client was able to successfully access SGDs presented at the evaluation with the following selection technique/modifications.

Direct Selection: Infrared Headpointer (Tracker, Headmouse)

Type: N/A

Additional Info: N/A

Scanning: N/A

Type: N/A, N/A

Additional Info: N/A

Requires multiple access methods? No

If Yes, Please

describe: N/A

Briefly describe Clients ability to use the access method and any modifications needed for success.

(keyguard, finger splint, stylus, switch mount, switch location)

John is unable to access a device through direct selection due to loss of motor control in his right side. There has been no control in his left side

since birth. He will need a head pointing option such as a embedded Tracker.

Mobility

Client is: / / Ambulatory / X/ Non-ambulatory

Assist used for mobility: Power wheelchair

For individuals using wheelchairs:

Wheelchair Mounting System: Will not be required

If a mounting system is required, please specify make/model of wheelchair:

Make: N/A

Model: N/A

With the above modifications/considerations, the Client possesses the physical abilities to effectively use a SGD and required accessories to

communicate.

Client will transport the SGD by: Wheelchair Mount

In pounds, the weight of SGD must be no more than: 6 lbs.

The physical size must not exceed (H x W x D): Vanguard Plus is 13– x 10– x 3–

Carrying case is required for transporting: / / Yes / X / No

Additional comments:

John will be able to use his wheelchair mount from his current Pathfinder to transport his new device.

Language Skills/Ability

Speech and Language Abilities Determined by: (check all that apply)

/ / Report by family, teachers, caretaker

/ / Informal assessment

/ / Observation

/ / Trial therapy

/ / Formal testing

Formal tests administered:

Approximates single word spelling at the 4th grade level.

The Client presents with moderate impairment in language functioning as it relates to using an appropriate SGD. The Client possesses the following

skills/abilities:

Receptive Language

/ / Attends when spoken to

/ / Appears to recognize name

/ / Understands references to items that are out of sight

/ / Understands frequently used words

/ / Understand one or two part directions

/ / Understands simple questions

/ / Understands virtually everything that is said to Client

It is difficult to determine what is understood due to Client's motor handicap, but individuals familiar with Client report he/she understands most that is said to him/her.

Additional receptive language information:

N/A

Expressive Language

Communicates expressively using: (check all that apply)

/X / Pointing

/ / Signing N/A

/ / Eye gaze

/ / Vocalizes/approximates words N/A

/ / Uses single pictures/symbol to convey a message

/ X / Uses multiple pictures/symbols to convey a message

/ X / Uses single word to convey a message N/A

/ / Uses words to convey message N/A

/ / Uses spelling to convey a message

/ / Uses word prediction to convey a message

/ / Can use all three methods of organizing vocabulary; Single-meaning

pictures, Multiple-meaning pictures, spelling/word prediction.

Additional expressive language information:

N/A

When Client's receptive and expressive language skills are compared, Client appears to understand significantly more than he/she is able to

communicate, indicating the need to focus on expanding his/her ability to communicate.

Pragmatics

/ / Uses language for different purposes Feelings, Requesting, Protesting

/ / Changes language according to the listener or situation

/ / Gives background information to an unfamiliar listener

/ / Speaks differently in the classroom than during recess

Follows rules for conversation: Stays on topic, Uses facial expressions and eye contact.

Although Client uses non-symbolic strategies such as facial expression for a few of the different purpose of communication, he/she is unable to

communicate this information using language.

Reading

Functional reading is: Paragraphs

Additional reading comprehension information:

N/A

Writing

/ / Unable to produce written language

/ / Produces written language by: Typing

/ / Produces written communication using: Words (independent),

Sentences

SGD must use this method for message production: A combination of spelling, words and pictures

Nature of the message the client was able to generate: Phrase

How much instruction did the client require to produce messages: Minimal

Describe the cueing needed for message generation: No assistance or cueing.

Provide additional details as needed to support the Client's potential use of an SGD for functional communication in ADL's:

N/A

The Client's linguistic performance with the SGDs presented during the evaluation indicated the necessary language skills to communicate using a

SGD.

Cognitive Abilities

Level of impairment in cognitive functioning: Mild

Length of assessment and/or training trials: One month

Picture 11.png Picture 10.png

The Client demonstrates the necessary cognitive abilities (i.e., attention, memory, and problem-solving skills) to learn to use a SGD to achieve

functional communication goals.

Provide additional details as needed to support the Clients cognitive ability to use or learn to use an SGD for functional communication in ADL's:

John currently uses a speech generating device, Pathfinder. He is fully capable and has the cognitive ability to use such a device. His cognition

falls within functional limits. He was able to retain instructions without difficulty. He was able to create phrases using icons as well as spelling

methods.

Daily Communication Needs

Picture 12.png

Ability to Meet Communication Needs With Non-SGD Treatment Approaches

Speech therapy to improve/increase functional speech is not a viable option to meet the Client's communication needs because:

/ / The Client has a degenerative condition for which speech therapy to improve/increase functional speech production is not effective.

/ / The Client received speech therapy for n/a with no significant increase/improvement in functional speech production.

/ / The client's speech functioning has been static for n/a and no improvement is expected.

Briefly explain why natural speech and/or low tech communication methods are not effective. For example, caregivers do not know sign language, need to get attention from a distance, talk on the telephone.

Johns is unable to sign due to his motor control.

The results of the communication needs assessment as documented in the previous section indicate the majority of Client's daily functional

communication needs cannot be met with natural speech and/or low tech communication devices. Therefore the Client requires a SGD to achieve

and/or maintain functional communication ability in activities of daily living.

Functional Communication Goals

The Client's immediate, short term and long term goals and estimated times to completion following receipt of the recommended SGD are

Functional Communication Goals Picture 5.png

Input & Output Features

Input Features

Output Features

Language Characteristics and Device Features

Picture 16.png Picture 15.png

Other Features or Options

Picture 18.png

Equipment Evaluated and Device Code

Recommended Speech Generating Device Code

Based on the Client's communication needs and considering the Client's visual, hearing, physical, language and cognitive status as well as

specified features described in this report, SGD's in this Medicare/CPT code category are recommended: E2510 (synthesized, multi access, multi

message)

Speech Generating Devices and Accessories Evaluated

You must consider 3 or more SGD–s for the client. List the SGDs and accessories that were considered during the assessment. Include the product name and the manufacturer for each SGD:

ECO 14 with integrated headpointing Vanguard with integrated headpointing Vantage with integrated headpointing (all of the above devices are manufactured by Prentke Romich Company)

SGD Evaluation

Procedures used for evaluating the SGD's

When assessing the Clients ability to use the selected SGDs the following procedures were used:

The ECO, Vanguard, and Vantage were presented to the John. These devices we used because they all feature Unity, which the client is familiar

with due to him using the Pathfinder. Since he was familiar with the Vanguard, John was able to produce sentences and phrases with all three

devices. John did have trouble viewing the smaller icons (144 locations) on the ECO. He found that Vantage also too small. He was most

efficient on the Vanguard. He was able to successfully access the device with the embedded Tracker. He was not able to access any of the

above devices with direct selection even with a keyguard present.

Outcome of the SGD evaluation

For the following reasons the Vanguard device was selected as the most appropriate SGD for the Client. Briefly explain why the selected SGD is the best fit based on client needs (specifications) and SGD features:

The Vanguard was the easiest for John to view. The device will be mounted on his power chair with his current mount, so weight is not a factory.

John is familiar with Unity, so he will not have to –relearn– language. He was able to successfully one, two, three word phrases, and spell.

The other SGDs evaluated were ruled out for the following reasons:

Size was too large or too small

Speech Generating Device and Accessories Recommended

The individual's ability to achieve functional communication goals requires the acquisition and use of the SGD, mounting/carrying devices and

accessories listed below. This SGD represents the clinically most appropriate device for John Doe.

Please specify the product details for the order. For example: the color of the SGD and/or the size of the keyguard. Part numbers and product

options are available in our catalog or in our e-Store. Please click the Store link at the top of the page for the current product offerings.

If a wheelchair mount is being requested, please view our E-Store or current catalog for the type of mount and the specifications of the mount. For example, bar length and tubing size should be selected. This information is needed prior to the submission of a request to the third party payer(s).

Support, Treatment Plan and Signature

Client/Family Support of Speech Generating Device

Please indicate the Client's family or support person(s) present at the evaluation who are supportive of the necessity of the SGD for meeting the

Client's communication needs: Immediate family

Physician Involvement Statement

This report was forwarded to the treating physician, James Smith, ; (330) 222-3333, on 7/16/2008. The physician was asked to write a

prescription for the recommended SGD and accessories.

Treatment Plan

The client's treatment goals would best be met in this type of setting:

A combination of group and individual treatment

SLP Assurance of Financial Independence and Signature

The Speech-Language Pathologist performing this evaluation is not an employee of and does not have a financial relationship with the supplier of any SGD.

Picture 20.png

====================================================

EXAMPLE 4 BY DYNAVOX:

FOR SAMPLE USE ONLY – Please retain for your records

Evaluation Report Structure for Funding of

Speech Generating Devices

Request for Speech Generating Device (SGD) Funding:

Section 1: Demographic Information

· Patient: full name, complete address & telephone number

· Date of Birth

· Medical Diagnosis (do not list code)

· Communication Diagnosis (do not list code)

· Date of onset

· Medicaid/Medicare/Insurance Number(s)

· Primary Contact: complete address, telephone number & relationship to

patient

· Physician: full name, complete address & telephone number

· SLP: full name, complete address & telephone number

· Date of SLP evaluation, date of report

Section 2: Current Communication Impairment

A. General Statements

1. Impairment type and severity

Indicate type of communication impairment

· Describe impairment severity

This section should explicitly demonstrate how the medical condition results in

severe expressive speech impairment.

2. Anticipated Course of Impairment

· This section should demonstrate the current status and the expected

course of the speech impairment as it relates to the underlying

disease/condition.

· Indicate the expected course of impairment for conditions that are

stable as well as those that are progressive

· EXAMPLES: "The patient has severe dysarthria due to cerebral palsy.

The condition is stable and speech intelligibility is not expected to

improve;" or "The patient has severe dysarthria due to amyotrophic

lateral sclerosis. Currently speech rate is ## (half of normal),

indicating an expected precipitous decline in intelligibility. Speech

intelligibility will continue to deteriorate. This patient will require use of

an SGD throughout the course of this disease."

Rev. 1/2009

B. Comprehensive Assessment

1. Hearing Status

· Describe the communicator's hearing relative to communicating

with a SGD (along a continuum from normal hearing to deafness).

· Include communication partner's status, if relevant.

· Include specifics (if related to SGD use/selection) regarding acuity,

localization, understanding of natural speech, understanding

speech generated by an SGD.

· The report should state: "The patient possesses the hearing

abilities to effectively use an SGD to communicate functionally."

2. Vision Status

· Describe the communicator's vision relative to using an SGD (along

a continuum from normal vision to blindness).

· Include the following elements if/when pertinent to SGD

use/selection: acuity, visual tracking, visual field, lighting needs,

angle of view, size of symbols, contrast (color, detail), and spacing.

· The report should state: "The patient possesses the visual

abilities to effectively use an SGD to communicate functionally.”

3. Physical Status

· Describe pertinent considerations regarding motor skills,

ambulatory status, positioning and seating.

· Describe how the person will access the SGD (direct selection,

scanning) and the person's access requirements.

· Describe if accommodations may be required over time to deal with

changes in physical access. Keep in mind, however; that Medicare

will not cover items that are needed for future rather than current

medical necessity.

· The report should state: "The patient possesses the physical

abilities to effectively use an SGD and required accessories to

communicate."

· This is the area of the report where recommendations for

accessories (keyguard, switch, mount, etc..) are indicated.

4. Language Skills

· Describe the level of linguistic impairment (no impairment to severe

language impairment) as it relates to the person's ability to use an

SGD.

· Consider describing:

o performance on any language assessments completed

o competency of ability to develop functional language skills

Rev. 1/2009

o type and level of symbol use by the individual. Does person

require pictographic symbols, words, letters, and/or a

combination of symbols?

o linguistic capacity to formulate language/messages

o level of independence in formulating messages using

language

5. Cognitive Skills

· Describe the level of cognitive impairment (no impairment to

significant cognitive impairment) as it relates to the person's need

for and ability to use an SGD.

· Describe the person's attention, memory, and problem-solving skills

as they relate to using an SGD to enhance or develop daily,

functional communication skills.

· The report should state: “The patient possesses the

cognitive/linguistic abilities to effectively use an SGD to

communicate and achieve functional communication goals.”

· EXAMPLE: Mr. Smith's attention, memory and nonverbal problemsolving

skills are within functional limits. He sustained attention for

a two-hour evaluation, recalled how to turn on and off an SGD

(after initial instruction), and independently navigated between two

pages on an SGD. He has the attention, memory and problemsolving

skills to use an SGD to achieve his functional

communication goals."

Section 3: Daily Communication Needs

A. Specific Daily Functional Communication Needs

· This section should list the person's daily functional communication needs in areas described:

o Communication to enable person to get physical needs met (e.g.,

ability to communicate in emergency situations, directing behavior

of caregivers, advocating for him/herself, communicating with

family, friends, medical professionals or clergy using the phone)

o Communication to enable person to obtain necessary medical care

and participate in medical decision-making, (e.g., reporting medical

status and complaints, asking questions of medical providers,

responding to medical provider's questions, discussing choices for

end of life care, communicating with medical providers by phone).

o Communication to enable person to carry out family and

community interactions.

Rev. 1/2009

B. Ability to Meet Communication Needs with Non-SGD Treatment Approaches

·This section should document why the patient is unable to fulfill daily

functional communication needs using natural speech (or speech aids)

and non-SGD treatment approaches.

o Discuss success of speech therapy (to date and future prognosis) without an SGD

o Discuss the individual's ability to use low-tech strategies and natural modes of communication to met daily functional communication needs.

o Discuss why an SGD is required in addition to, or instead of low tech strategies and natural speech.

o Show explicitly that other forms of treatment have been considered and ruled out.

o Mention issues related to communicating with primary partners and caregivers in specific contexts.

· The report should state: "The patient's daily functional communication needs cannot be met using natural communication methods or lowtech/ no-tech AAC techniques because of ______________________ (be specific).

Section 4: Functional Communication Goals

Documented goals MUST be a part of the justification report.

· Document 2-3 goals in each time frame, short (2-3 mo), intermediate (6 mo.) and long term (1+ yr.) to be achieved after the device has been delivered.

· Goals should correspond to specific daily functional communication needs

(including specific contexts and communication partners as well as

communication functions) and illustrate how the patient will benefit from the acquisition of and training on the SGD.

EXAMPLES:

Adult oriented

o 1) Mr. ___ will be able to independently communicate physical needs and emotional status to his wife on a daily basis, as needed within 2 months.

Rev. 1/2009

o 2) Ms. ___ will describe her physical symptoms and ask any questions when interacting with her physician and other health care professionals as needed within 6 months.

o 3) Mrs. ___ will engage in social communication exchanges with immediate family and extended members in person and by use of the telephone within 1 year.

Child oriented

1) ___________will answer (wh) questions by sequencing a minimum of 3 pictures/words from at least 2 category pages on his

communication device (master page, action words, things and/or describing words) ) to express a novel and grammatically correct thought ( eg. I like bubbles), within 6 months.

2) Using the QWERTY keyboard on his communication device ________________ will independently spell out simple novel answers to questions using word prediction, editing keys and speak keys as needed 80% independently, within 1 year.

Section 5: Rationale for Device Selection

This section will explain why certain device features are required. The rationale will relate the person's skills and abilities as described in Section 2.

This section provides data that leads first to the selection of a specific device code and second to a specific device within that code, as well as specific accessories.

In order to make these decisions, SLP's may work with OT's, PT's, Rehab Engineers, and use AAC devices, computer or manual simulations to gather

pertinent data.

The report should state: "This individual requires a speech generating device with (list specific features) to meet the person's functional communication goals."

A. General Features of Recommended SGD and Accessories

1. Input Features/Selection Technique

A. Direct Selection

· Keyboard/Display: dynamic/static, number of keys/locations

· Activation Type: touch sensitive, pressure sensitive, adjustable

· Optical pointer, head mouse, eye gaze, other (specify)

B. Scanning

· Display: number of keys, dynamic/static

· Mode: visual, auditory

Rev. 1/2009

· Type of scan: linear, row/column, group/row/column, directed

(joystick, trackball), adjustable speed

· Switch: type (pressure, feedback), position, mount

C. Encoding Type

· Position, category, semantic compaction, numeric, alphabetic, Morse code, other (specify)

2. Message Characteristics/Features

A. Type of Symbols

· Tactile, pictures (note quality, color vs. black & white), symbols (commercially available, individualized), words, phrases, letters

B. Storage Capacity

· Message length needed

· Number of different messages being stored or formulated

· Other (specify)

C. Vocabulary Expansion and Rate Enhancement

· Screens or levels

· Word prediction

· Other (specify)

3. Output Features

· Voice Output

· Visual Display

· Feedback

4. Other Features (NOTE: These relate to AAC accessories)

· Portability

· Size and weight, transport/mount, case/carrier requirements

· Battery time required

· Other

5. Description of Equipment Used and/or Considered During the Evaluation

· Include evidence that the individual was present and actively

participated in the assessment process. Discuss assessment outcomes that demonstrate the person's ability to use the SGD and recommended accessories.

· Discuss other SGD’s considered and why they were not

appropriate for this user (for example if recommending a

device in the E2510 codes you must rule out another device in codes E2508 and E2506). You do not have to try each device considered with the user if it can be ruled out without a trial.

· Please include low tech as well as high tech devices.

6. SGD and Accessories Recommended

· List the specific SGD and accessories and include medical

justification as to why this SGD and specifically the accessories

being requested will enable the patient to achieve functional

communication goals, as stated earlier in the report.

The report MUST state, "The individual's ability to achieve his/her functional communication goals requires the acquisition and use of the (name the device) and (name the specific accessories). This SGD (and these accessories) represents the clinically most

appropriate device (equipment) for (name of client)."

"Using my clinical expertise, I have determined that the XYZ device (and accessories) is (are) the most appropriate means of communication for John Doe.

(If trial was completed or required, please make sure to mention that, “John has had an adequate trial with the XYZ device or similar device, therefore I am recommending a purchase of this device (equipment) for John.”)

Recommended Equipment

___________________________________________

EXAMPLES:

E2510 Series 5 V

E2512 Wheelchair Mounting System – to position the SGD in the

optimal place for effective visual and physical access of the device.

Switch Mount – this mount is necessary to position the switch in

the proper place for optimal use.

E2599 User Accessible Carry Case – for protection of the device while be used throughout the day and during transport.

Keyguard – this plastic piece with holes cut in it to coordinate with

the communication squares on the SGD, will provide support and

guidance for direct access of the desired square and will help

alleviate “miss hits”.

EyeMax - The patient is experiencing weakness of the upper and

lower extremities, his respiratory musculature, laryngeal

musculature and oral/facial musculature. He is able only to

consistently move his eyeballs laterally and vertically, to indicate

yes and no responses to his caregivers. This leaves him virtually

“locked in” his own body. Eye gaze is the only functional

movement this patient can achieve, therefore and eye gaze system

is the only method of access available.

Headmouse or Tracker Pro – this is an alternate access device

where the user will move their head to control a pointer on the

screen. This pointer will activate the desired square when the user

dwells on it.

7. Patient and Family Support of SGD

· Discuss participation of the family/caregiver/advocate and state that they agree to the selected SGD (and accessories) and will support the equipment and its use for daily communication.

8. Physician Involvement Statement

· The report should state:

"This report was forwarded to the treating physician

Name ________________________________________

Address ______________________________________

City, State, Zip _________________________________

Telephone # __________________________

on _______(date), so that he/she can write a prescription for the

recommended SGD and accessories."

· NOTE: The date that the SLP forwards the SGD device assessment report should be BEFORE the date on the doctor's prescription.

Section 6: Treatment Plan

Address all functional communication goals previously stated for the beneficiary and identify the plan for achieving these goals using the SGD and accessories.

· Frequency of SLP treatment

· Schedule of functional goal achievement

· Operational competency achievement dates

· Functional communication goals achievement dates

· Treatment plan with a training schedule for the selected

device and accessories

· Type of Treatment (individual vs. group)

· Projected Frequency of Reassessment

· Follow-up Requirements for SGD and Accessories

o Individual(s) responsible for programming

o Individual(s) responsible for troubleshooting

Section 7: Functional Benefit of Upgrade

· If the recommendation is for an upgrade of a device, provide documentation as to what has changed with the individuals’ medical status and/or why their current SGD does not meet their medical needs.

Section 8: SLP Assurance of Financial Independence and Signature

· The report should state: "The SLP performing this evaluation is not an employee of and does not have a financial relationship with the supplier of any SGD."

· SLP signature

· Evaluating SLP's name & contact information (agency, address & telephone number)

· ASHA Certification Number

· State License Number