Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Central Nervous System/Neuromuscular Disorder. 
Treatment:  Speech generating device.
 
The insurer denied the Speech generating device.  The denial is overturned in whole.

The patient is a male.  According to a letter by a nurse practitioner, the patient has diagnoses, which include hypotonia, intellectual disability, genetic abnormality, delayed motor milestones, and childhood apraxia of speech.  He had a barium swallow test performed, which indicated that he had ineffective swallowing and inability to protect his airway.  It was recommended that he have soft food and that food is cut into small bite-sized pieces.  He needs to be fed at a slow rate.  He needs to be able to communicate these needs to his caregivers.

Letters by his speech therapist describe that the patient is functionally non-verbal and unable to communicate due to childhood apraxia of speech.  He has intellectual disability and is unable to communicate by writing.  He has been using a ProSlate device as a means of augmentative-alternative communication (AAC) for the past 5 years.  The device is a first generation device, and both his speech therapist and an Augmentative-Alternative Communication Technologist, explain that the device no longer supports updates to the speech application (app).  It is having technical problems with significant lag time and page jumps.  As a result, the patient is unable to communicate with his caregivers regarding his feeding needs, when he needs a medical mask or bathroom break.  He has become frustrated, banging on the desk with his fist, engaging in self-injurious behavior, and pushing his AAC device toward the teacher.  He has withdrawn from interaction with his peers.  A letter by a speech therapist describes that the patient's ProSlate device no longer holds its charge during the schooldays.  The battery is flat by 12 noon.

Both speech therapists, as well as the AAC technologist, have recommended that the patient be provided with an updated AAC Speech Generating Device, namely the Forbes ProSlate8 with the TouchChat communication app and corresponding 42-button keyboard.

The subject under review is the medical necessity for the speech generating device.

The health plan's determination is overturned in whole.

The requested health service/treatment of Speech Generating Device is medically necessary for this patient.
 
A new Speech Generation Device, as recommended by his speech therapy providers, is medically necessary for this patient, who has been documented to be at risk of aspirating and choking on food.  It is imperative that he be able to communicate with his caregivers, if he is having difficulty swallowing.  His current AAC device is not working properly, having a lag time and improperly loading pages.  These delays put the patient's life at risk.  He is intellectually disabled and cannot express himself by writing.  He also needs to be able to communicate if he needs to use the bathroom.  

Choking is fourth leading cause of death in young children.  The most common objects on which children choke are food [1].  A retrospective review by DeRowe et al. of 328 children treated for aspiration of food matter at a tertiary care children's hospital found that 52 (15.9%) were identified with neurological impairment.  Compared with the non-impaired children, those with neurological impairment were older, diagnosed later, hospitalized longer and had a higher incidence of complications [2].

A Position Statement by the American Speech-Language-Hearing Association (ASHA) [3] states that "Eligibility policies and practices often preclude children and adults with severe disabilities from accessing needed communication services and supports."  The authors continue "It is the position of the National Joint Committee for the Communication Needs of Persons with Severe Disabilities that eligibility for communication services and supports should be based on individual communication needs.  Communication services and supports should be evaluated, planned, and provided by an interdisciplinary team with expertise in communication and language form, content, and function, as well as in augmentative and alternative communication (AAC)."

The National Joint Committee for the Communication Needs of Persons with Severe Disabilities (NJC) established a Communication Bill of Rights for individuals with disabilities [4,5] that states, "All people with a disability of any extent or severity have a basic right to affect, through communication, the conditions of their existence.  Beyond this general right, a number of specific communication rights should be ensured in all daily interactions and interventions involving persons who have severe disabilities."  Clause 11 is, "The right to have access to functioning AAC (augmentative and alternative communication) and other AT (assistive technology) services and devices at all times." [6]