Amyotrophic Lateral Sclerosis (ALS)

 

Requirements for a Funding Request for a SGD

These are the Medicare criteria for coverage of a SGD. Remember, a thorough evaluation will cover more components than these seven (7) criteria in order to recommend the SGD that will result in the most effective communication for your abilities, skills, and changing needs. If one or more of the SGD coverage criteria is not met, the SGD will be denied as not medically necessary. Therefore, as an informed participant on your ALS team, you should review your request and ask appropriate questions to ensure coverage of the required criteria.

The speech generating device is covered when all of the following criteria (1-7) are met:

1. Prior to the delivery of the SGD, a formal evaluation of cognitive and communication abilities has been performed by a speech-language pathologist (SLP). The formal, written evaluation must include, at a minimum, the following elements:
a) current communication impairment, including the type, severity, language skills, cognitive ability, and anticipated course of the impairment;
b) an assessment of whether the individual's daily communication needs could be met using other natural modes of communication;
c) a description of the functional communication goals expected to be achieved and treatment options;
d) rationale for selection of a specific device and any accessories;
e) demonstration of a treatment plan that includes a training schedule for the selected device;
f) the cognitive and physical abilities to effectively use the selected device and any accessories to communicate;
g) 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;

2. The individual's medical condition is one resulting in a severe expressive speech impairment;

3. The individual's speaking needs cannot be met using natural communication methods;

4. Other forms of treatment have been considered and ruled out;

5. The individual's speech impairment will benefit from the device ordered;

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;

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