RetiredCapital BluecrossPolicy MP 6.032

Speech Generating Devices

Governs medical necessity criteria, coding, and coverage considerations for speech generating devices and related accessories for members of certain Capital Blue Cross products.

Policy Summary

PayerCapital Bluecross

PolicySpeech Generating Devices

Policy CodePolicy MP 6.032

Change TypeRetirement and coding updates

Effective Date

Next Review Date

Key ActionProvide a formal written SLP evaluation reviewed and approved by the treating/ordering physician that documents communication impairment, assessment of natural methods, rationale for device selection, a treatment/training plan, and functional benefit.

SourceLink

POLICY UPDATE CHANGES

New code E3000 was added effective 1/1/2024.

New code E2513 was added effective 10/1/2024.

Policy retired effective 11/1/2025.

MP 6.032Policy identifier

Retired 11/1/2025Status/date

3+ updatesCoding history

7+Citations

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Medical necessity criteria for SGD

Covered when ALL of the following are met:

SLP evaluation and physician review: There is clinical documentation that the patient has had a recent formal evaluation of their cognitive and communication abilities by a speech-language pathologist (SLP) and the evaluation has been reviewed and approved by the treating/ordering physician; the formal, written evaluation must include specified elements (current communication impairment; assessment of natural communication modes; functional communication goals and treatment options; rationale for device selection; treatment plan with training schedule; assessment of cognitive and physical ability to use device; for upgrades, documentation of functional benefit compared to the prior SGD).

See documentation module for element list.

Severe expressive speech impairment: The patient's medical condition results in a severe expressive speech impairment.

Natural communication insufficient: The patient's speaking needs cannot be met using natural communication methods.

Other treatments considered: Other forms of treatment have been considered and ruled out.

Anticipated benefit: The patient's ability to communicate will benefit from the device ordered.

Accessories

Accessories covered when ALL of the following are met:

Base device criteria met: Coverage criteria for the base SGD device are met.

Accessory necessity documented: The medical necessity for each accessory is clearly documented in the formal written evaluation by the SLP.

Accessories include access devices, replacement batteries/chargers, and mounting systems.

The existence of this medical policy does not mean that the service is a covered benefit under the member's health benefit plan. Benefit determinations must be based on the member's applicable health benefit plan language. Medical policies do not describe benefits and do not replace the terms of the member's plan, which govern coverage, exclusions, benefit limits, and preauthorization requirements.

Not all services referenced in this policy are necessarily covered for every member. Coverage, exclusions, and any benefit limits vary by product and plan design; members and providers should consult the specific health benefit plan or contact Capital Blue Cross to determine whether a particular service is a covered benefit for that member.

Provider Actions, Authorization & Documentation

Prior Authorization

Prior Authorization Required

Prior authorization: Prior authorization may be required per payer rules. Verify benefit plan and obtain any required prior authorization before device procurement or billing.

Affected coding: see Coding Information section for relevant CPT/HCPCS; authorization requirements vary by plan.

Documentation Required

Required Documentation — SLP Evaluation and Physician Review

The formal, written SLP evaluation must be completed and available in the medical record and must be reviewed and approved by the treating/ordering physician before approval of an SGD or accessory. The SLP evaluation must include at minimum: current communication impairment (type, severity, language skills, cognitive ability, anticipated course); assessment of whether daily communication needs could be met using natural modes of communication; description of functional communication goals and treatment options; rationale for selection of a specific device; a treatment plan including a documented training schedule; assessment of cognitive and physical ability to use the device and accessories; and for upgrades, information on the functional benefit compared to the originally provided SGD.

Documentation Required

Conservative Management Requirement

Conservative management must be tried and documented prior to approval. Documentation must show that other forms of treatment were considered and ruled out and that the patient's speaking needs cannot be met using natural communication methods. The SLP evaluation should describe prior interventions and the clinical rationale for proceeding to an SGD.

Denial Risk

Denial Triggers

Triggers for denial include missing or incomplete SLP evaluation, lack of documented physician review/approval of the evaluation, failure to document that conservative management was attempted or deemed inappropriate, and inability to demonstrate that the patient's speaking needs cannot be met with natural communication methods or that the device meets the patient’s communication needs.

Background

Speech generating devices (SGDs), also referred to as augmentative and alternative communication devices, provide electronic or digitized speech for individuals with severe expressive speech impairment who cannot meet communication needs through natural methods. Selection and provision of an SGD typically requires a formal evaluation by a speech-language pathologist (SLP), documentation that natural communication methods are insufficient, and coordination with a multidisciplinary team to train the user and caregivers on device use and maintenance.

Definitions

Durable Medical Equipment (DME) — key attributes

DefinitionDurable Medical Equipment (DME): items that are primarily and customarily used to serve a medical purpose; are not useful to a person in the absence of illness or injury; are ordered by a physician; are appropriate for use in the home; are reusable and can stand repeated use.

Primary useServes a medical purpose rather than general utility.

Not useful when wellNot useful to a person in the absence of illness or injury.

Physician orderMust be ordered by a physician.

Home useAppropriate for use in the home setting.

DurabilityReusable and able to withstand repeated use.