Speech Generate Device denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for a Tobii Dynavox Pilot® speech generating device with gaze interaction and mounting system. The primary rationale for the use of augmentative and alternative communication (AAC) is the inability of a patient to use natural speech to meet all of their daily communication needs. AAC may be used to augment or replace communication for patients with cerebral palsy who are unable to communicate with familiar and unfamiliar communication partners in all situations. Patients may use AAC regardless of their age or current cognitive skills. The use of AAC should encompass a life span perspective. The Researchers report that AAC is multimodal, permitting individuals to use every mode possible to communicate.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and authorization and coverage for authorization and coverage for a Tobii Dynavox I-13 Speech Device (CPT E2510), an eye gaze interaction accessory (CPT E2512), and a mount (CPT E2599).Graziola and colleagues have explained that children with GNAO1 mutations usually need to use a wheelchair and have numerous motor constraints, including dystonic movements and postures and hypotonia, making cognitive assessment difficult. This contributes to their disability, resulting in a high level of frustration for both caregivers and patients. Graziola and colleagues evaluated six children with GNAO1 mutations and found that these children showed variable degrees of communicative intent through intentionally directed gaze.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for an augmentative and alternative communication device. The use of speech generating devices (SGDs) may be indicated for certain patients with autism and language impairments. This includes patients who have severe functional language impairments who cannot achieve their goals with verbal language. The use of an SGD requires a formal evaluation by a speech language therapist who evaluates the need to augment speech. The therapist should evaluate the ability of the patient to use the device, determine goals for the use of the device, and include it in a therapy treatment plan. In order to benefit from the device, the patient must show the ability to use the device independently. In this case, the patient has autism with language impairments.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Speech Generate Device, then check the rights and deadlines that apply to your plan.