Speech Generating Device is Medically Indicated for This Patient
Yes, a Speech Generating Device (SGD) such as the Tobii Dynavox is medically indicated for this patient with apraxia and phonological disorder, particularly given the good prognosis and comprehensive therapy plan already in place. The evidence strongly supports SGD use in apraxia, and the patient's profile—including ongoing speech therapy, functional communication goals, and professional recommendation—meets established criteria for medical necessity.
Evidence-Based Rationale for SGD Use in Apraxia
Apraxia as a Motor-Phonological Disorder Requiring AAC Support
Apraxia of speech is fundamentally a disorder of motor planning or programming that results in difficulty volitionally producing correct speech sounds, with articulatory disturbances and prosodic deficits including slow rate and restricted pitch variations 1.
The disorder affects intelligibility, naturalness, and efficiency of communication, negatively impacting social participation, psychosocial well-being, and quality of life disproportionate to the severity of the physiological impairment 1, 2.
Apraxia represents a systematic reduction in linguistic complexity where patients simplify consonant production through marked-to-unmarked phonological changes 3, making augmentative support particularly valuable for functional communication.
Direct Evidence Supporting SGD Effectiveness in Apraxia
A case study of a 2-year-old with severe childhood apraxia of speech demonstrated that SGD implementation led to immediate increases in communicative development and increases in all linguistic variables (intelligibility, consistency of speech productions, lexical and grammatical development) with only an 8-9 session latency effect 4.
Research synthesis of 35 studies involving 86 participants with developmental disabilities showed positive outcomes in 86% of studies using SGDs, with 54% providing conclusive evidence for effectiveness 5.
SGDs have been shown to enhance both communicative and linguistic competencies in young children with severe apraxia, contrary to outdated concerns that AAC might inhibit natural speech development 4.
Medical Necessity Criteria Met
Clinical Appropriateness
The patient has a permanent communication impairment (apraxia with phonological disorder) that significantly limits functional verbal communication—this meets the fundamental criterion that most funding sources require for SGD coverage 1.
The good prognosis with SGD use, as documented by the evaluating provider, demonstrates expected functional benefit—a key requirement for medical necessity 1.
The comprehensive treatment plan (individual therapy 3 times weekly for 6 months targeting functional communication goals) provides the therapeutic framework necessary to maximize SGD effectiveness 1.
Team-Based Assessment Completed
Assessment by qualified professionals (speech-language pathologist and occupational therapist) with specific SGD recommendation satisfies the interdisciplinary evaluation requirement that guidelines emphasize 1.
The evaluation has identified functional communication goals and determined that the SGD will meet daily communication needs—this goal-oriented approach aligns with best practice standards 1.
Integration with Ongoing Therapy
SGD as Augmentation, Not Replacement
Research definitively shows that AAC systems do not decrease natural speech use; rather, they facilitate natural speech production in children with speech potential 1.
The SGD should be viewed as augmenting the patient's deficient communication abilities while residual speech abilities continue to develop through concurrent speech therapy 1.
The intensive therapy schedule (3 times weekly) provides adequate opportunity to train on the device and integrate it across communication contexts 1.
Behavioral Interventions Remain Primary
Individually tailored behavioral interventions targeting physiological support for speech (respiration, phonation, articulation, resonance) should continue as the cornerstone of apraxia management alongside SGD use 1, 2.
Speech and language therapy remains essential and should be provided intensively according to patient needs, goals, and severity 2.
Critical Implementation Considerations
Device Selection and Training
High-tech SGDs like the Tobii Dynavox offer advantages including ease of progressing skill levels, extensive vocabulary capacity, portability, and ability to connect to other devices—making them appropriate for patients with good prognosis 1.
However, a low-tech backup solution (picture/word board) should always be available when battery power is depleted or technical issues arise 1.
Training must occur across environments and with multiple communication partners to ensure functional use beyond the therapy setting 1.
Monitoring and Adjustment
The assessment-implementation-monitoring cycle must be repeated periodically as the child develops and needs change 1.
Follow-up evaluation should ensure the system meets functional communication goals and that the patient is progressing in both SGD proficiency and underlying speech abilities 1.
Common Pitfalls to Avoid
Do Not Delay SGD Implementation
Waiting for "proof" of permanent disability or requiring exhaustive trials of speech therapy alone before providing SGD access can deprive patients of critical communication access during formative periods 1.
Early SGD exposure promotes facility in use and supports language development rather than hindering it 1, 4.
Avoid Excessive Dependence Concerns
While guidelines caution against "excessive dependence on aids to communication" in functional voice disorders 1, this concern does not apply to patients with neurologically-based apraxia where the motor-planning deficit is the primary pathology 6, 3.
The patient's apraxia represents a genuine motor-phonological sequencing disorder requiring augmentative support, not a functional/psychogenic communication disorder 6.
Funding Justification
Medical Necessity Letter Components
The prescription or medical necessity letter should state that the physician reviewed evaluation reports and concurs that the SGD is medically necessary for treatment of communication impairment caused by apraxia and phonological disorder 1.
Include the patient's current communication status, expected functional outcomes with the device, and how it will address specific daily communication needs 1.
Document that the device is essential for the patient to achieve functional communication across settings (home, school, community) and that less sophisticated solutions are insufficient given the severity and nature of the disorder 1.
Appeal Preparedness
If initial funding is denied, appeal immediately with supportive letters from the speech-language pathologist and physician emphasizing functional benefit and medical necessity 1.
Successful appeals establish important precedents for future requests and prevent funding barriers for other children with similar disabilities 1.