Is the use of a Speech Generating Device (SGD) medically necessary for a patient with severe dysarthria, aphonia, and difficulty with speech coordination resulting from a large pontine hemorrhage?

Medical Necessity of Speech Generating Device for Pontine Hemorrhage with Severe Dysarthria

This Speech Generating Device (SGD) is medically necessary and meets all established criteria for this 22-year-old male with permanent severe dysarthria, aphonia, and communication impairment following pontine hemorrhage.

Alignment with Medical Necessity Criteria

The patient's case fulfills all required medical necessity criteria established by Aetna and supported by clinical guidelines:

Permanent Severe Expressive Speech Disability

• The patient has permanent severe dysarthria and aphonia resulting from a large pontine hemorrhage, which represents a permanent neurological condition causing severe expressive speech disability 1, 2
• The impairment is documented as permanent with reduced speech intelligibility expected to be chronic, meeting the requirement for a medical condition resulting in permanent severe expressive speech disability 1
• Pontine hemorrhage with resulting dysarthria represents a permanent structural neurological injury that will not resolve with time alone 3

Formal Speech-Language Pathologist Evaluation

• A comprehensive SLP evaluation has been completed documenting all required elements including functional communication goals, treatment plan with training schedule, assessment of natural communication modes, and demonstration of cognitive and physical abilities to use the device 1, 2
• The evaluation documents that the patient can read, comprehend, and physically operate the SGD using mouse system despite bilateral lower extremity paresis and left hemiparesis 2

Failure of Natural Communication Methods

• Natural communication methods have been systematically ruled out: the patient cannot rely on speech due to severe dysarthria and aphonia, cannot perform sign language due to dexterity limitations (left upper extremity unusable, limited right hand function), and cannot use communication boards due to dexterity limitations 1, 2
• The patient can only initiate some short words and phrases inconsistently, with speech that is effortful and difficult to understand by both familiar and unfamiliar listeners, demonstrating inadequacy of natural speech 1
• Alternative low-tech and mid-tech options have been appropriately trialed and failed, meeting the requirement that other forms of treatment have been considered and ruled out 1

Demonstrated Ability to Benefit

• The patient has already demonstrated ability to use the SGD effectively with mouse system access, can read and comprehend, and has the cognitive capacity to operate the device 2, 4
• The patient's ability to communicate basic expressions including medical needs is severely impaired without the SGD, and the device will enable functional communication for safety, medical decision-making, and quality of life 5, 6

Clinical Evidence Supporting SGD Use

Stroke and Communication Impairment

• Stroke patients with severe communication impairments should be considered for assistive technology and communication aids by appropriately trained clinicians 1
• Alternative means of communication including augmentative and alternative communication devices are appropriate when natural speech is inadequate 1, 2
• SGDs improve quality of life by optimizing function, assisting with decision-making, and providing opportunities for personal growth in patients with severe verbal communication impairment 5

Effectiveness of SGD Intervention

• SGDs have demonstrated effectiveness across multiple populations with severe communication impairments, with positive outcomes reported in 86% of studies and conclusive evidence in 54% of studies 4
• Multi-functional SGD systems tailored to hospitalized suddenly speechless patients have demonstrated high satisfaction levels and independent use, with patients considering the technology of high importance 6
• SGDs can effectively enhance both communicative and linguistic competencies in patients with severe speech impairments 7

Access Method Appropriateness

• The mouse system represents a medically necessary alternative input device given the patient's inability to use standard input methods due to bilateral lower extremity paresis, left hemiparesis, and limited right hand function 1
• A variety of access devices including head control mouse and pointers are medically necessary to enable persons with neurologic conditions to use an SGD 1

Standard of Care Considerations

This treatment plan is considered standard of care and is not experimental or investigational:

• Medicare regulations authorize medically necessary SGDs for all beneficiaries with functional communication needs and permanent severe expressive speech disabilities 1
• The American Academy of Pediatrics (applicable principles extend to adults) recognizes SGDs as critical assistive technology for communication impairments when natural communication methods are inadequate 1
• Stroke guidelines from the Australian Stroke Foundation and UK guidelines specifically recommend consideration of assistive technology and communication aids for stroke patients with communication problems 1

Critical Documentation Elements

The case documentation appropriately includes:

• Diagnosis of permanent neurological condition (pontine hemorrhage with resulting dysarthria and aphonia) 1
• Formal SLP evaluation with all required components including functional goals, treatment plan, assessment of natural communication modes, and device selection rationale 1, 2
• Documentation of failed conservative treatments (inability to use sign language, communication boards) 1
• Demonstration of ability to use the device (able to use mouse system, read, comprehend) 2, 4
• Medical necessity for specific access method (mouse system due to motor limitations) 1

Important Caveats

• The SLP performing the evaluation must not be an employee or have a financial relationship with the SGD supplier to meet medical necessity requirements 1
• Only one SGD at a time is considered medically necessary per patient; multiple devices would require exceptional documentation 1
• Follow-up training and reassessment are critical for successful SGD implementation, though funding for these services may require separate authorization 1
• The device should include capability to generate email, text, or phone messages to allow remote communication, which is a medically necessary feature 1

This SGD represents the appropriate standard of care for this patient's permanent severe communication impairment and will significantly impact his ability to communicate medical needs, participate in decision-making, and maintain quality of life 1, 5, 6.