An insurance request for an AAC system requires specific information. Each funding source (insurance, Medicaid, Medicare, etc.) and state may have different requirements. Below is a guide to writing a report for insurance submission based on common Pennsylvania funding sources. Please note that this is for example purposes only. Information may need to be added and/or deleted. Each report must also be individualized with appropriate recommendations based on the client.
For additional support with writing insurance requests, most major speech-generating device vendors have funding departments who can provide assistance and report templates.
Below is a guide to each section of the report and prompts for your writing:
Reason for Evaluation
Describe the evaluation process, who provided information (family, teachers, team, etc.) and a summary of the measures used (records/IEP review, anecdotal information, observation, surveys, etc.).
Example: CLIENT, a X-year, X-month old GENDER, was seen on DATE OF EVALUATION for an augmentative and alternative communication evaluation. The purpose of the evaluation was…
Include relevant background information about the client such as medical, family, school, and therapy information. Provide medical and speech-language diagnosis ICD-10-CM codes. Don’t forget a statement about concerns with “functional communication skills”!
Impairment Type and Severity
Describe the speech-language diagnosis and explain how this impacts expressive language.
Anticipated Course of Impairment
Is the client’s current communication status stable? Are these life-long diagnoses? Is the client expected to develop functional oral speech? Does the client’s natural speech meet his/her daily communication needs? Will the use of a speech-generating device be lifelong? What goals will obtaining a speech-generating device achieve?
Describe the following:
- Hearing Status
- Visual Status
- Physical Status
- Mobility Status
- Attention/Behavior Status
- Social Status
- Oral Motor/Speech Skills
- Cognitive Skills
- Reading/Literacy Skills (if needed)
- Communication Skills
- Receptive language
- Pragmatic language
- Expressive language (what communication modalities does the person use?)
Describe how the individual’s forms of communication alone are not sufficient to meet the needs of the client. Explain how and why a speech-generating device is necessary to meet these needs.
Daily Communication Needs
Discuss the individual’s communication partners (who does he/she communicate with on a daily basis?), communication environments (where does he/she need to communicate?), and communication activities/abilities/participation (what types of communicative acts does he/she engage in?).
Describe the limitations of his/her current communication modalities. Explain why these are not sufficient and why a speech-generating device is MEDICALLY necessary.
Ability to Meet Communication Needs with Non-Speech-Generating Device Treatment Approaches
Explain how speech-language therapy alone, natural speech, and use of electronic aids/other non-speech-generating device approaches do NOT meet the needs of the client. For example, why is PECS or light tech options not going to meet his/her needs? Why are sign language and gestures not sufficient for this client?
Describe how a speech device will benefit the client. Explain how a speech-generating device is MEDICALLY necessary.
Rational for Device Selection
Input/Out Features and Selection Technique
Explain which features of the device the individual requires for success and provide a justification for each. For example, will the client use manual direct selections, scanning, etc. to use his/her device? Does the client need an on-screen keyboard or predictive text? Does this client need voice output/synthesized speech?
Language System Characteristics
Describe the type of language system characteristics the individual needs for functional communication. Do they require folder/category based vocabulary, core vocabulary, grammar support features, phrase/sentence based messages, etc.? Does the individual require a bilingual language system? Provide a justification for these features.
Explain features of the device itself that are necessary for the individual to successfully utilize it. Are specific editing/programming features required (e.g., hiding icons, importing photographs, color contrast, etc.)? Consider the device portability, battery length, size/weight of the device, etc. Provide a justification for these features.
Additional Features and Accessories
This section will be needed if an individual needs any additional equipment (e.g., keyguards, mounting, switches, etc.) to use the device. Describe these features/accessories and provide a justification for each.
Recommended Speech-Generating Device Code
The E2510 Medicare/CPT code category is used for speech-generating devices with synthesized speech, permitting multiple methods of message formulation and multiple methods of device access (e.g., including but not limited to: QuickTalker Freestyle, Choice Communicator, PRio, Accent, Tobii i-series, NovaChat, etc.). Additional codes for other types of speech-generating devices
Outcome of the Speech-Generating Device Evaluation
Describe the AAC systems and devices considered/trialed. Most insurances will require at least 3 total systems to be discussed in the report. Explain why the systems/devices not selected are NOT the most appropriate system for the client. For the selected system/device, be sure to describe why this device is medically necessary and allows for functional communication.
Speech-Generating Device and Accessories Recommended
Name the specific device. Provide a rationale for the selection of the device. Discuss how this device meets the needs of the individual and what features it has. Provide justification for these features (reiterate information from sections above!). Include the following information:
- Speech-generating device and/or accessory name
- Medicare CPT code for each item
- Vendor name, address, and phone number for each item
Discuss the recommended treatment plan for the individual. Include both short term (within 4-6 months of obtaining device) and long term (within 1 year of obtaining device) goals/objectives. Provide any recommendations for additional evaluation and therapy services.
Physician Involvement Statement
List the treating physician’s name and information. State that this report was submitted for their review.
SLP Assurance of Financial Independence
The speech-language pathologist performing the evaluation must state whether they are an employee of or if they have a financial relationship with a supplier of any speech-generating device.
Be sure to sign off and date the completed report. Include contact information, as well as ASHA certification and state license numbers.
For more resources on insurance requests for AAC, check out the Insurance Resources article.