CHECKLIST FOR SPEECH EVALUATION REPORT

A speech generating device 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:

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 that the patient possesses 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; 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.