Medicare Funding Pages

1. Example of individual with TBI

Facility Name
Department of Speech-Language Pathology
Facility Address and Phone Numbers

MEDICARE FUNDING REQUEST
FOR SPEECH GENERATING DEVICE (SGD)

I. DEMOGRAPHIC INFORMATION

II. CURRENT COMMUNICATION IMPAIRMENT

A. General Statements

Impairment Type & Severity (ICD-9 Diagnostic Code: 784.5)
Patient presents with a profound dysarthria and apraxia. Has left facial weakness. Oral motor control limited to gross movements only (e.g. slight opening & close of right side of mouth). Patient is unable to phonate on command. Unable to elicit phonation during automatic speech tasks (e.g. sigh, laugh).

Anticipated Course of Impairment
Patient is > 10 years post-injury. Dysarthria and apraxia are judged to be stable and chronic.

B. Comprehensive Assessment

Hearing
No problems with hearing noted or reported. Discriminated sentences on SGD with synthetic speech with 100% accuracy.

Vision
Patient is legally blind. Reports seeing light, some colors, and forms. The patient cannot rely on vision to access an SGD, but can use Morse code or auditory input.

Physical
Functional Status: Patient is wheelchair dependent, quadriplegic, legally blind, fully assisted for self-care. Receives all nutrition through gastrostomy tube.

Seating and Mobility: Patient has Quickie P190 power wheelchair with joystick located for attendant control. Sits comfortably for extended time periods. No problems reported or noted. Patient has manual chair. Will return to Seating Center for proper fitting. Needs access to communication system from both chairs.

Motor Control: Limited to approximately 1/4 to 1/2 active range of motion right elbow and shoulder for internal and external rotation. Functionally, patient can access area of approximately 8" wide X 5" deep when target centered on his lap. Is able to extend fingers of right hand in patterned movements, can isolate thumb to move anteriorly and posteriorly along the surface of his index finger.

Access to Devices: Dual switch Morse code input.

Language Skills
Language falls within functional limits. The patient answers personal yes/no questions with 100% accuracy and follows 2 step directions with 100% accuracy. Approximates single word spelling at the 6.0 grade level (KTEA). Generates simple written sentences without difficulty.

Cognitive Skills
Cognition falls within functional limits. Patient functions at Rancho Los Amigos Level VIII (Purposeful Appropriate). The patient attended to a 1 hour evaluation, without need for redirection by the therapist. Retained task instructions without difficulty. Spelling and written language are functional for communication purposes. The patient had maintained previously mastered Morse code skills. Identified logical codes to abbreviate messages. Codes did not follow consistent format. However, patient retained codes after a 20-minute time delay.

The patient initiates conversation (by tapping finger, pressing buzzer). Comments or questions appropriate to topic. Maintains topic without difficulty.

III. DAILY COMMUNICATION NEEDS

A. Specific Daily Communication Needs

Primary communication situations involve 1:1 and group conversations.

Primary communication environments are home and day program. Patient also expresses a desire to communicate at church and has opportunities to go into the community with mother.

Patient's primary communication partners include his mother, caregivers, extended family, and staff at day program.

Patient's daily functional communication needs requirement to communicate messages that convey basic needs to various partners and provide direction to caregivers who are less familiar with his needs. He also needs to choose activities, express interests and give opinions.

B. Ability to Meet Communication Needs with non SGD Treatment Approaches

The patient received traditional speech language therapy immediately following his injury when he was an inpatient in an acute rehabilitation hospital. Medical records indicate the patient received approximately 1 hour of therapy/day for approximately 6 weeks. The records indicate that no significant changes were noted in oral motor function, however language and cognitive abilities showed moderate improvement. Subsequent screenings, conducted at least annually in outpatient clinics, reported no functional improvements in oral motor function. Given the current severity of the patient's speech, medical diagnosis, and time post onset, prognosis for developing functional speech is judged to be poor.

Patient has had Light Talker for approximately 10 years. Accessed device through Morse code. Device is old and no longer functioning on a consistent basis. Device is no longer manufactured and very difficult to obtain repairs. When Light Talker was operational, patient relied on the device as his primary means of communication.

Currently, the patient relies on yes/no responses (slight nod and eye brows up for "yes"; slight shake of head for "no"); facial expressions, and spelled messages using Morse code (uses thumb and index finger of right hand to simulate "dots" & "dashes"). Also has buzzer that gives auditory feedback. The patient uses yes/no responses and facial expressions to indicate very basic needs to trained and familiar caregivers. Use of Morse code with his fingers or the buzzer is only effective with people who know Morse code (i.e. the patient's mother).

The patient's current communication approaches do not permit him to convey the type and complexity of messages in the environments and with those partners with whom he interacts on a daily basis. Currently the patient is dependent on his mother for interpreting all novel communication needs.

A low technology solution, such as an alphabet board, is not appropriate for this patient because he is blind. The patient's speaking needs cannot be met using natural communication methods or low-technology approaches. The patient requires SGD to meet his functional communication goals.

IV. FUNCTIONAL COMMUNICATION GOALS

Upon receipt of an SGD, therapy will target the following goals. The patient will demonstrate ability to:

• Convey basic needs to caregivers, by spelling or retrieving preprogrammed message on SGD, independently and with 100% accuracy (to be met within 2 weeks).
• Communicate complex needs and ideas, through the SGD, during face-to-face and group social situations, independently and with 100% accuracy (to be met in 1 month).
• Communicate needs and ideas to a range of partners in various communication situations, using various strategies to expedite message production, independently and with 100% accuracy (3 months)

V. RATIONALE FOR DEVICE SELECTION

A. General Features of the Recommended SGD and Accessories

The SGD needs the following input and output features:

• Input: 2 switch Morse code input, accessible from both wheelchairs, alphabet based with access to stored messages (i.e. abbreviation expansion).
• Output: Text-to-speech speech synthesis (given that patient has novel message needs and is relying on spelling as primary means to generate messages), auditory feedback.
• Other features: Portable to accommodate conversational needs in various locations with home and community. Long lasting battery to ensure device is operational in various locations and to minimize need to be close to electrical outlet. Wheelchair and switch mounts that allow access to SGD.

B. Recommended Medicare Device Category and Accessory Codes

The individual's ability to meet daily communication needs will benefit from acquisition and use of the SGD Category 5 (K0545). The patient's family has a laptop computer that he can use when he obtains appropriate communication software. The patient also requires wheelchair and switch mounting systems (K0546) and switches (KO547) to access the SGD.

C. Trials with SGDs and Accessories

After demonstration only, the patient successfully used EZ Keys software with Morse code to generate novel, sentence length messages. The patient required occasional cues to toggle between the word processor and side-talk. As the patient becomes familiar with the operational requirements of the program, it is anticipated that he will perform this function independently. The patient also needed occasional cues to use strategies to expedite message production (e.g. abbreviating words, shortening messages). Cues were required because cognitively, the patient has difficulty shifting or alternating his attention from generating complete text to simplifying text. The fact that the patient needs cues has no impact on the understandability of the messages he produces; the strategies only influence the rate of message production.

The caregiver successfully interpreted all of the patient's messages relying on synthesized speech output. Because the patient needs Morse code access, the trial was limited to the EZ Keys program.

D. Recommended SGD and Accessories

The patient will use his family's laptop computer and his current switching system. It is recommended that he be fitted with:

1. * EZ Keys -a software program that offers all required features and will enable the individual to achieve the designated functional communication goals.

EZKWINEZKeys with Voice Output for Windows

2. Patient also requires two AbleNet Specs switches for access to the SGD.

(2) SPECS2 AbleNet Specs Switches

3. Patient also requires a wheelchair mounting system. The mount is required for efficient and independent access, as well as to secure the SGD and keep it stable.

Mount specifications are as follows:

*Slim Armstrong Switch Mount:

SLIMARMSlim Armstrong Switch Mounting System

*DaeSSy Frame clamp to adapt current mount arm to fit on the patient's manual wheelchair :

UFC1000IP and UFCOPFrame Clamp Inner Piece and Outer Piece for 1" diameter tubing

*DaeSSy Laptop mount plate to securely attach the communication system to the mount arm

PC-COMP/QRP1PC laptop holder (must specify make/model of laptop at order)

*EZ Keys and Mount are available from:
Words+, Inc Phone: (805) 266-8500 x112
40015 Sierra Hwy, Bldg B-145 FAX: (805) 266-8969
Palmdale, CA 93550

E. Patient and Family support of SGD

The patient and his mother have used an SGD in the past. With training and support, the caregiver will be able to maintain the equipment. Given the patient's proficiency with Morse Code, he recognized that EZ Keys is the optimal device for his needs.

F. Physician involvement statement

A copy of this report has been forwarded to the patient's treating physician (DR. … #XXX) on ______ (date) for review and prescription.

VI. TREATMENT PLAN

Upon receipt of SGD recommend 6-8 individual one hour sessions for patient adaptation and training for augmentative alternative communication (AAC) are recommended. Sessions will focus on the functional communication goals identified in Section IV.

VIII. SIGNATURES /SLP ASSURANCE OF FINANCIAL INDEPENDENCE

The Speech-Language Pathologist performing this evaluation is not an employee of and does not have a financial relationship with the supplier of the SGD.

____________________
XXX MS CCC-S
Speech Language Pathologist
ASHA #
State Lic.
Note: Signatures of other team members are not required by Medicare, but should be included when available.

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2. Example of individual with Moderate Receptive Aphasia, Severe Expressive Aphasia and Moderate Apraxia of Speech

Facility Name
Department of Speech-Language Pathology
Facility Address and Phone Numbers

MEDICARE FUNDING REQUEST
FOR SPEECH GENERATING DEVICE (SGD)

I. DEMOGRAPHIC INFORMATION

II. CURRENT COMMUNICATION IMPAIRMENT

A. General Statement

Impairment Type & Severity (ICD-9 Diagnostic Code: 784.3, 784.69 )
As a result of a sudden onset left unilateral CVA in 1998, patient, age 55 years, presents with a moderate receptive and severe expressive aphasia across all modalities with concomitant moderate apraxia of speech.

Mr. ____(Patient) is functionally non-speaking. Patient's primary means of communication are inconsistent gestures, facial expressions, exaggerated changes in vocal intonation, and inconsistent yes/no head nods.

Anticipated Course of Impairment : Aphasia and apraxia are judged to be stable and chronic in nature.

B. Comprehensive Assessment

Hearing
Family denies hearing problems for patient or primary communication partners. Patient passes bilateral pure tone audiometric screening at 25 dB for octave frequencies from 500-4,000 HZ. Attends and responds to auditory information presented at conversational loudness levels. Understands digitized speech and good quality synthetic speech equally well as judged by appropriate responses and reactions to message output. Possesses hearing abilities to effectively use SGD to communicate functionally.

Vision
Patient wears bifocals. Corrected visual acuity is within normal limits. No other visual impairments are noted. Discriminates 12-point font and 1/2 inch symbols on SGDs. Patient possesses visual skills to use SGD functionally.

Physical
Patient demonstrates moderate right hemiplegia with minimal use of right upper extremity (formerly dominant hand). Ambulates using a quad cane. Safely carries small items (< 5 lb.) with a shoulder strap. Uses a manual wheelchair for ambulating long distances. Does not propel wheelchair independently.

Patient can independently access SGD with left arm/hand and depress keys with left index finger. Demonstrates adequate movement and pressure to activate both a membrane keyboard and touch screen. Possesses physical ability to independently and effectively carry, maintain, and access SGD.

Language Skills
Patient demonstrates moderate receptive and severe expressive aphasia and concomitant moderate apraxia of speech as formally measured on the Western Aphasia Battery :

Overall Aphasia Quotient: 18.8/100
Spontaneous Speech Score: 1/20
Auditory Comprehension Score: 8.4/10
Naming Score: 0/10
Reading: 28/100
Writing: 20.5/100

Informally, patient demonstrates functional understanding of basic adult conversation, presented at moderate rates. Comprehension improves when gestural and written cues are provided.

Patient demonstrates ability to manage SGD displays with 30 items. Identifies printed words on a display of 30 with 50% accuracy. Rate of selection is slow, frequently taking > one minute. When printed words are enhanced with picture symbols on a display of 30, the patient demonstrates 90% accuracy with functional selection rates. Demonstrates ability to spell some functional words. Uses word prediction with 80% accuracy, but rate of selection is > 30 seconds (choice of 10 words).

During a 2-hour evaluation, the patient masters independent use of up to 30 categories to access 30 screens of vocabulary/stored phrases (20-30 symbols/screen). Spontaneously uses vocabulary to answer questions or establish a topic, but does not formulate two or three- part messages.

Cognitive Skills
No formal testing was conducted due to severity of patient's aphasia and language demands of standardized tests. Informally, the patient shows excellent attention and motivation to communication tasks over a 2-hour period. Recalls symbol locations and device operations/instructions. Initiates communication spontaneously and manages basic operations on/off/delete independently. Possesses linguistic and cognitive ability to use SGD to communicate functionally.

III. DAILY COMMUNICATION NEEDS

A. Specific Communication Needs

Primary communication situations involve 1:1 and small group conversations.

Primary communication environments are home, telephone (emergency and exchange with grown children who live out of town), and community.

Patient's primary communication partners include his wife, family, friends, and health professionals.

Patient needs to communicate messages that provide identifying/biographical information, express physical status/needs, socialize, offer information about past and present experiences, and express feelings and opinions with familiar and unfamiliar communication partners across multiple environments.

B. Ability to Meet Communication Needs With Non-SGD Treatment Approaches

Patient has not shown speech improvement with traditional speech language therapy (Weekly 1 hour individual therapy 1998-2000). Given the time post onset and current severity of the patient's expressive aphasia and apraxia of speech, the patient is judged to have minimal to no potential to develop speech. Patient does not have adequate spelling skills to support writing as primary mode for expressive communication.

Currently, patient is limited to communicating about objects/activities in the immediate environment (points to them), confirming or rejecting (fair reliability), answering some questions related to needs by pointing to written choices, and relying on family members' interpretations of vocalizations and facial expressions. Patient has attempted to use a word/picture communication book, but found that either vocabulary was too limiting or when additional vocabulary pages were added, one-handed page turning with the left/non-dominant hand was cumbersome/nonfunctional

Patient lives at home with his wife. She reports difficulty understanding patient's requests for specific items. She notes patient is limited in his ability to communicate with other family members and friends. Patient's inability to communicate on the phone interferes with his potential to maintain contact with his two children who are away at college.

As a result, Mr. ____'s daily functional communication needs cannot be met using natural communication methods or low-tech/no-tech AAC techniques.

IV. FUNCTIONAL COMMUNICATION GOALS

Upon receipt of an SGD, treatment goals will target use of SGD in face-to-face interactions, on the telephone, and in daily communication situations to spontaneously:

• Provide identifying/biographical information to familiar partners on 8/10 opportunities (within 1 month)
• Offer information about present or past events to familiar and unfamiliar partners on 8/10 opportunities (within 3 months)
• Express feelings and opinions to familiar and unfamiliar partners on 8/10 opportunities (within 3 months).

V. RATIONALE FOR DEVICE SELECTION

A. General Features of Recommended SGD and Accessories

Based on the above noted comprehensive assessment, daily communication needs, and functional communication goals, the patient requires SGD with the following features:

Input/Message Characteristic Features:

• Visual word/picture symbol displays for minimum of 30 symbols
• Dynamic touch screen/direct selection and categorical encoding
• Minimum 50 levels on which to store extensive vocabulary/messages
• Pre-programmed dictionary of functional vocabulary
• Word prediction

Output:

• Synthesized voice output/text to speech capability

Other features:

• Lightweight (e.g. < 5 lb) and portable with shoulder strap/independent patient transport
• Minimum battery time 4 hours to insure availability.

Accessories

• Carrying case so device can be transported safely and independently
• Back-up Card that enables custom vocabulary displays to be backed up and retrieved if necessary

B. Recommended Medicare Device Category and Accessory Codes

The individual's ability to meet daily communication needs will benefit from acquisition and use of the SGD Category E2510 and accessories (carrying case and backup card) from SGD Accessory Code E2599.

C. Trial with SGDs

The patient and his wife participated in a two-hour evaluation. The patient was introduced to several SGDs which offer word/picture displays and voice output. In an attempt to introduce the patient to both digitized and synthesized devices, the clinician trialed devices in several categories.

E2500 - Tech Talk 8 (under 8 minutes of recording time – E2500) – not enough vocabulary and difficulty switching levels manually.

E2502 - Multi Level Message Mate 40 (between 8 and 20 minutes of recording time - E2502) – not enough vocabulary and difficulty switching levels.

E2504 - Dynamo (25 minutes of recording time – E2504) With >20 words/symbols on a Dynamo display, symbols are unclear and interfere with patient's symbol selection accuracy and rate. In addition, since the device has only digitized speech, the patient is unable to make use of text-to-speech synthesis for (occasional) spelled formulation of utterances.

E2510 - Enkidu Tablet Impact XL (E2510) exceeds size/weight criteria for the patient to carry it independently/safely. While the patient is occasionally able to identify first letters of words in conversation on the keyboard pages, the system lacks word prediction with pictures to facilitate word retrieval. However, patient demonstrates ability to select items from the display, to navigate among screens, and to utilize device to produce messages in response to questions.

E2510 – DynaVox MT4 (E2510) With the MT4 patient demonstrates ability to use a personalized screen to provide 20 items regarding identifying/biographical information (name, address, phone, family members, education/work history, etc.). Navigates between 30 screens on verbal command with 70% accuracy. Answers object function wh-questions with 75% accuracy. Offers information for picture description activity with 70% accuracy. Expresses feelings/opinions with 60% accuracy. Uses Child User dictionary two times to find vocabulary not available on custom screens. Functionally types/uses word prediction for 12 words in conversation. In addition, he demonstrates an ability to use the carrying case to transport the device.

D. SGD and Accessories Recommendation

Based on SGD trials, it is recommended that the patient be fitted with:

(E2510) MT4 (insert serial number from company) - to improve functional communication.
(E2599) MT4 Carrying Case (insert serial number from company) - to protect SGD in transit and to enable client to access system in a variety of communication settings
(E2599) MT4 Back-up Card (insert serial number from company) - to back-up custom vocabulary.

These items are available from:

DynaVox Systems, Inc.
2100 Wharton Street
Pittsburgh , PA 15203
1-888-697-7332

E. Patient and Family Support of SGD

The patient is highly motivated to use an SGD to improve his communication. His wife supports the use of the MT4 and demonstrates good entry-level ability to program the MT4. With additional training and support, the wife will be able to independently program and maintain the equipment.

F. Physician Involvement Statement

A copy of this report has been forwarded to the patient's treating physician (DR. … #XXX) on ______ (date) for review and prescription.

VI. TREATMENT PLAN

Upon receipt of SGD, it is recommended that the patient receive 8 one-hour individual and 8 one-hour small group patient therapy sessions within 3 months. These sessions will address goals listed in Section IV of this report. An additional two hours of training are recommended to further train the patient's wife to program and maintain the device.

VIII. SIGNATURES / SLP ASSURANCE OF FINANCIAL INDEPENDENCE

The Speech-Language Pathologist performing this evaluation is not an employee of and does not have a financial relationship with the supplier of the SGD.

____________________
XXX MS CCC-S
Speech Language Pathologist
ASHA #
State Lic.
Note: Signatures of other team members are not required by Medicare, but should be included when available.

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3. Example of individual with Severe Aphasia and Severe Apraxia of Speech

1. Example of individual with TBI

Facility Name
Department of Speech-Language Pathology
Facility Address and Phone Numbers

MEDICARE FUNDING REQUEST
FOR SPEECH GENERATING DEVICE (SGD)

I. DEMOGRAPHIC INFORMATION

II. CURRENT COMMUNICATION IMPAIRMENT

A. General Statement

Impairment Type & Severity (ICD-9 Diagnostic Code: 784.3)
As a result of a sudden-onset ruptured cerebral aneurysm and subsequent hypoxic episode in 1993, Mr. ___, age 66 years, presents with severe aphasia across all modalities and concomitant severe apraxia of speech. Mr. ___(Patient) is functionally non-speaking. Patient's primary means of communication are inconsistent gestures, exaggerated changes in vocal intonation, and inconsistent yes/no head nods.

Anticipated Course of Impairment:Aphasia and apraxia are judged to be stable and chronic in nature.

B. Comprehensive Assessment

Hearing
Family denies hearing problems for patient or primary communication partners. Patient responds at screening levels of 1000, 2000, and 4000 Hz bilaterally when tones are presented at a cutoff level of 30dB in a quiet room. Patient attends and responds to auditory information presented at conversational loudness levels. Understands digitized speech and good quality synthetic speech equally well as judged by appropriate responses and reactions to message output (80 % accuracy). Possesses hearing abilities to effectively use SGD to communicate functionally.

Vision
No visual acuity problems are noted. Patient demonstrates severe visual field cut in lower right quadrant. Does not compensate unless cued. Demonstrates best accuracy (85%) identifying picture symbols when ten 2-3" color symbols/display are presented in top-down array or left of midline. Possesses visual skills to use SGD functionally.

Physical
Patient ambulates for short distances by cruising from furniture item to item. Spends 50% of day in manual wheelchair. Moves independently to a table (potential location of SGD) by ambulating or propelling his wheelchair. In community environments, the patient will have the SGD velcroed to a bean bag lap desk which he carries in his lap.

Patient can independently access SGD with left arm/hand and depress keys with left index finger. Demonstrates adequate movement and pressure to activate both a membrane keyboard and touch screen. Requires partner assist to change levels/overlays on all devices. Possesses physical ability to effectively use SGD.

Language Skills
The patient demonstrates severe aphasia and concomitant severe apraxia of speech as formally measured on the Western Aphasia Battery:

Overall Aphasia Quotient: 11/100
Spontaneous Speech Score: 1/20
Auditory Comprehension Score: 2.5/10
Naming Score: 0.8/10
Reading: 15/100
Writing: 2.5/100

Because of the patient's limited ability to communicate through text or speech, a symbol assessment was conducted using an informal clinician-made task according to criteria from Beukelman and Mirenda (1998) as well as the Multimodal Communication Assessment Task for Aphasia (Garrett, 1998). Results include:

• ability to identify familiar photos of family members in response to name and contextual phrases (85%)
• ability to identify color-enhanced black and white line drawings of objects representing daily needs and wants (e.g. peanut butter, bathrobe) in response to name and contextual phrases (78%)
• ability to locate symbols given an array of ten 2" symbols arranged vertically and/or to the left (75%)
• ability to understand conversational phrases stored on a digitized SGD when activating its corresponding symbol as demonstrated by appropriate actions and facial expressions (70%)
• ability to locate and activate symbols and digitized messages in response to a realistic role-play regarding needs or structured conversational questions on SGD display containing ten symbols arranged by topic and in top/bottom order given minimal cues/occasional assistance (65%)
• inability to sequence symbols-therefore messages would have to represented holophrastically.

In conversation, patient demonstrated ability to follow basic commands and follow basic conversation when gestural and written cues were provided.

Cognitive Skills

The patient sustains attention for up to one hour if communication partners facilitate his understanding with use of gestural and written communication cues. Recalls symbol locations on a display from session to session. Attempts to initiate communication and independently reaches for the SGD. Turns SGD On-Off independently. Possesses linguistic and cognitive abilities to use basic SGD to communicate functionally.

III. DAILY COMMUNICATION NEEDS

A. Specific Daily Communication Needs

Primary communication situations involve 1:1 and small group conversations.

Primary communication environments are home, telephone (emergency and exchange with grown children who live out of state), and to a lesser extent, community.

Patient's primary communication partners include his wife, caregivers, family, and visitors.

Patient needs to communicate messages that convey needs/physical problems/ pain, greetings and basic social exchange, leisure activity choices, and information about recent/past events to the primary communication partners across communication environments.

B. Ability to Meet Communication Needs with Non-SGD Treatment

Patient has not shown speech improvement with traditional speech-language therapy (1 hour individual therapy, weekly/1993-4, 1 hour group therapy, weekly/1998 to present). Given the time post onset and current severity of the patient's oral apraxia, apraxia of speech, and severe aphasia, the patient is judged to have minimal to no potential to develop speech. In addition, due to profound agraphia, the patient did not write functional words except for his signature.

Currently, the patient is limited to communicating about objects in the immediate environment (picks them up), confirming or rejecting (fair reliability), answering some questions related to needs by pointing to written choices, and relying on caregivers interpretations of vocalizations and facial expressions. Patient's wife reports consistent difficulty understanding patient's needs and interests. Patient has experienced minimal improvements in functional communication with a picture communication book. Points to picture to establish topic, but remains dependent on wife to try to interpret for self and others, as patient cannot formulate complete messages. Patient's daily functional communication needs can thus not be met by natural communication or low-tech/no-tech augmentative communication.

IV. FUNCTIONAL COMMUNICATION GOALS

Upon receipt of SGD, treatment goals will target use of multiple displays on SGD (6-8 symbols per display) in real-life situations to*:

• Express needs/physical problems/pain during interactions with family, caregivers and medical personnel in person and on telephone with min/mod verbal cues with 80% accuracy (within 1 month)
• Choose leisure activities with min/mod verbal cues with 80% accuracy (within 1 month)
• Express greetings and social exchanges with family and friends with min/mod verbal cues with 80% accuracy (within 1 month)
• Offer information about recent/past events to familiar and unfamiliar partners with min/mod verbal cues with 80% accuracy (within 2 months)
• Participate in phone conversation with out of town family members with min/mod verbal cues with 80% accuracy (within 2 months)

*The communication partner will consistently be responsible for setting up the correct message level.
Development of these skills will provide patient opportunity for increased control and socialization with a variety of partners in numerous different communication situations.

V. RATIONALE FOR DEVICE SELECTION

A. General Features of Recommended SGD and Accessories

Based on the above noted comprehensive assessment, daily communication needs, and functional communication goals, the patient requires SGD with the following features:

Input/Message Characteristic Features:

• Membrane keyboard or touch screen for direct selection with LUE
• Static display
• Large (1 ½ -2") color picture symbols (Picture Communication Symbols or DynaSyms and Words)
• Capability to create divisions/spaces between pictures
• 10-12 levels on which to store messages

Output:

• Digitized (<8 minutes) or synthesized voice output

Other features:

• Portable enough for caregiver to carry in community
• Minimum battery time 2-4 hours to ensure availability.

B. Recommended Medicare Device Category and Accessory Codes

The individual's ability to meet daily communication needs will benefit from acquisition and use of the SGD Category K0541. No device accessories are required.

C. Trials with SGDs

The patient was seen for 3 individual and 2 group therapy sessions using the Tech/TALK 8 (under 8 minutes recording time - E2500), Tech/Speak (between 8 and 20 minutes recording time - E2502), MessageMate 40 (between 8 and 20 minutes recording time - E2502), and the DynaVox DV4 (E2510). The patient activates all keyboards successfully.

E2502 Devices: Tech/Speak (32 message squares) and MessageMate 40 (40 message squares) Becomes confused by displays with more symbols (e.g. Tech/Speak and MessageMate 40). Unable to access appropriate messages in a timely way during trial.

E2510 Device: Does not use categories to benefit from dynamic display and has difficulty navigating dynamic display pages. Does not formulate two-part messages/sentences.

E2500 Device: Tech/Talk 8 - On symbol displays with 6-8 messages, the patient increases the frequency of his purposeful communication attempts, increases his attention to peer speaker or clinician facilitator (from 40%-90%), and demonstrates success in locating messages stored on an SGD to answer conversational questions and make requests. Patient requires occasional cues to scan display to compensate for his right visual field cut.

D. Recommended SGD and Accessories

Based on SGD trials, it is recommended that the patient be fitted with the:
Tech/TALK 8 (TT23x8BG) a portable digitized voice (6.4 min recording time) output device with 8 large words/pictures per display and ability to store 12 levels/displays. This device has features designated as necessary to achieve Mr. ____'s functional communication goals and Mr. ____ has demonstrated the ability to use this device successfully in conversation.

*Available from:
Mayer -Johnson Company
PO Box 1579
Solana Beach , CA 92075
800-588-4548

E. Patient and Family Support of SGD

The patient is highly motivated to use an SGD to improve his communication. His wife supports the use of the Tech/TALK 8 and demonstrates good entry level ability to prepare overlays and program the device. With additional training and support, the wife will be able to independently program and maintain the equipment.

F. Physician Involvement Statement

A copy of this report has been forwarded to the patient's treating physician (DR. … #XXX) on ______ (date) for review and prescription.

VI. TREATMENT PLAN

Upon receipt of SGD, it is recommended that the patient receive 45 minutes of individual therapy and one hour of group therapy weekly for 8 weeks (total 16 sessions). These sessions will address goals listed in Section IV of this report. An additional two hours of training are recommended to train caregivers to program the device.

VIII. SIGNATURES / SLP ASSURANCE OF FINANCIAL INDEPENDENCE

The Speech-Language Pathologist performing this evaluation is not an employee of and does not have a financial relationship with the supplier of the SGD.

____________________
XXX MS CCC-S
Speech Language Pathologist
ASHA #
State Lic.
Note: Signatures of other team members are not required by Medicare, but should be included when available.

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70 YEAR OLD WOMAN WITH PROFOUND DYSARTHRIA SECONDARY TO ALS

Facility Name
Department of Speech-Language Pathology
Facility Address and Phone Numbers

MEDICARE FUNDING REQUEST
FOR SPEECH GENERATING DEVICE (SGD)

I. DEMOGRAPHIC INFORMATION

II. CURRENT COMMUNICATION IMPAIRMENT

A. General Statement

Impairment Type & Severity (ICD-9 Diagnostic Code: 784.3)

Secondary to ALS, Mrs. _____ presents with a profound dysarthria and is functionally nonspeaking. Produces differentiated vowels with varying intonation. Imitates monosyllabic words, with referent known, with 10% intelligibility.

Oral motor control limited to gross movements only, and these movements are imprecise, reduced in range and executed slowly (e.g. open - close mouth, protrude tongue). Patient receives nutrition through gastrostomy tube. Spontaneous speech is limited to vocalizations.

Anticipated Course of Impairment
Based on the Severe Dysarthria due to Amyotrophic Lateral Sclerosis Staging Scale (a 5-point scale, with 1 being no detectable speech disorder and 5 being no useful speech), patient's speech is characteristic of Stage 5 - No useful speech. Given the patient's current status and progressive nature of ALS, it is anticipated that Mrs. ___'s condition will deteriorate further.

B. Comprehensive Assessment

Hearing
No problems with hearing noted or reported. Patient passes pure tone audiometric screening for octave frequencies at 25 dB from 500- 4000 Hz. Attends to and discriminates natural and synthetic speech at conversational loudness levels. Husband may have slight hearing loss, although his hearing has yet to be formally assessed. Husband successfully discriminated synthetic speech n SGD, at sentence level, given occasional repetition (of spoken message) and reliance on visual display. Patient and primary communication partner possess hearing abilities to effectively use SGD to communicate functionally.

Vision
Patient wears bifocal glasses at all times. Shows no problems with visual attention, scanning, tracking, or acuity with glasses on. Discriminates ¼" text on display positioned at midline, at a distance of approximately 18", without difficulty. Possesses visual abilities to effectively use SGD to communicate functionally.

Physical
The patient is wheelchair dependent. Has an electric wheelchair (Jazzy 1100, with a right joystick controller). Drives chair independently and safely. Seating tolerance approximates 2 -3 hours. Patient referred to physical therapist for recommendations to improve seating comfort and tolerance. Patient spends several hours/day in a standard recliner chair. Needs access to SGD from both wheelchair and recliner.

Patient reports weakness in both upper extremities. Patient is right hand dominant. Able to type on standard keyboard using middle right finger and left index finger. Types quickly and with few errors. No indications of fatigue or discomfort after typing several sentences. Does not require keyguard at this point in time. Accommodations may be, scanning module/switch). Patient possesses the physical abilities to effectively use a SGD with noted accessories to communicate functionally.

Language Skills
Informal assessment reveals oral and written language skills within functional limits. Patient answers abstract yes/no questions with 100% accuracy and follows multistage directions with 100% accuracy. Answers multiple choice questions about a paragraph read silently with 100% accuracy. Types grammatically correct, syntactically complex sentences. Formulates meaningful written paragraphs independently.

Cognitive Skills
Patient retains task instructions without difficulty. Recalls 100% (5/5) of messages stored under abbreviations. Identifies logical codes to abbreviate messages. Spontaneously uses strategies to aid message production (e.g. abbreviates words) Consistently gives partner feedback (using SGD and nonverbal cues) to indicate if message is accurately interpreted. Corrects and clarifies messages as appropriate. Spontaneously and appropriately shifts between communication approaches to maximize communication efficiency. Demonstrates ability to use word prompting and prediction. Possesses cognitive/linguistic abilities to effectively use SGD to communicate and achieve functional goals.

III. DAILY COMMUNICATION NEEDS

A. Specific Daily Communication Needs

Primary communication situations involve 1:1 and small group situations. Primary environments are home and medical appointments. Primary communication partners include husband, daughter, friends, paid caregivers, and medical staff. Specific message needs include expressing needs, making requests, asking questions, offering information, and expressing feelings/opinions. Patient expresses strong desire to maintain her role as a decision maker in the home, to socialize with friends and family, and to communicate directly with medical staff regarding her disease and treatment.

B. Ability to Meet Communication Needs with Non-SGD Treatment

Patient has previously received speech maintenance therapy. However, given the current severity of the patient's speech impairment, coupled with the progressive nature of ALS, therapy to improve speech production is no longer indicated or appropriate.

The patient relies on yes/no responses, vocalizations, facial expressions, simple gestures (e.g. pointing to items in environment), alphabet board and desk top computer. Unaided approaches are effective for calling attention and indicating very basic needs (e.g. pointing to a cup to request drink).

The alphabet board is used to generate novel messages during face-to-face conversations with husband, daughter and a few close friends. The board is adequate for basic needs that require a 2 or 3 word message; messages exceeding 2-3 words are difficult for partner to decode/retain. The board also requires the partner to be standing beside the patient as she composes her message. This can be tedious and time consuming for all partners and is not tolerated by medical personnel. The board is ineffective in-group social situations, because not all partners can see the board and follow along as the patient spells. The board is not effective with hired caregivers because they cannot read English. The desktop computer is used to prepare messages in advance for either the husband or daughter. The computer is not portable nor does it have voice output.

The patient's current communication approaches do not permit her to convey the type and complexity of information in the environments and with those partners with whom she interacts on a daily (i.e. husband, daughter, care givers) or intermittent basis (i.e. physicians, friends).

IV. FUNCTIONAL COMMUNICATION GOALS

Upon receipt of an SGD, therapy will target the following goals. Ms.___(Patient) will:

• Demonstrate ability to master basic maintenance and operations of SGD (on-off, adjusting menu features such as voice and display) with 100% accuracy (within 2 weeks)
• Demonstrate ability to program stored messages independently with 100% accuracy (within 2 weeks)
• Convey basic needs/make requests to caregivers, by spelling or retrieving pre-programmed message on SGD, independently and with 100% accuracy (within 2 weeks).
• Initiate social greetings, offer information, ask questions, express feelings and opinions through spelling and retrieving stored messages on SGD, during 1:1 and group situations with familiar and unfamiliar partners, independently and with 100% accuracy (within 3 weeks).
• Use strategies on SGD to expedite message production when sharing information or asking questions of medical personnel, independently and with 100% accuracy (within 3 weeks).

V. RATIONALE FOR DEVICE SELECTION

A. General Features of Recommended SGD and Accessories

Based on the above noted comprehensive assessment, daily communication needs, and functional communication goals, the patient requires SGD with the following features:

Input/Message Characteristic Features:

• Direct selection with index and middle fingers of both hands/standard or mini keyboard (patient prefers QWERTY keyboard)
• Flexibility to accommodate changes in physical access (i.e. alternative keyboard, scanning)
• Accessible from multiple positions (i.e. wheelchair, Lazy Boy)
• Alphabet based with access to stored messages (i.e. abbreviation expansion)
• Access to word prompting or prediction to be used as physical access declines

Output:

• Text-to-speech speech synthesis (given that patient has novel message needs and is relying on spelling as primary means to generate messages)
• Two-way visual display to aid husband (who has suspected hearing loss) to interpret messages
• Capability to facilitate communication at a distance.

Other features:

• Portable to accommodate conversational needs in various locations within home and at medical appointments
• Long lasting battery to ensure device is operational in various locations and to minimize need to be close to electrical outlet.

B. Recommended Medicare Device Category and Accessories Codes

The individual's ability to meet daily communication needs will benefit from acquisition and use of the SGD Category K0543 and equipment that enable device to be mounted from SGD accessory code (K-0547).

C. Trials with SGDs

Patient participated in trials with 3 SGDs in Category K0543 that have the input and output features similar to those delineated above. The SGDs included DynaMyte/DynaVox 3100, the Link, and the LightWRITER SL35. Both current and future communication needs were considered as her physical condition is likely to deteriorate.

• DynaMyte/DynaVox 3100. Patient had difficulty with glare and motor access on the DynaMyte and DynaVox.
• Link. After demonstration only used the Link to generate novel messages. Used all function keys without difficulty. Given the battery limitations, the inability to alter access methods, and the small visual display the Link is not an optimal solution.
• LightWRITER SL35. The patient independently utilized the LightWRITER to communicate her needs. Spelled lengthy, complex messages without difficulty. Used function keys with 100% accuracy and recalled all messages stored under abbreviations. The husband successfully interpreted all of the patient's messages relying on speech output and the visual display. Any trial re: future features. I think we should include something that relates to scanning, e.g., patient was shown scanning features and was able to select messages using linear scanning.

D. Recommended SGD and Accessories

Based on comprehensive assessment and SGD trials, it is recommended that the patient be fitted with the LightWRITER SL35 and wheelchair mount to secure the device and allow independent access. The recommended wheelchair mount is designed to accommodate the LightWRITER and will enable her to use the device throughout most of the day.

LightWRITER and accessories are available from:

ZYGO Industries, Inc.
P.O. Box 1008
Portland, OR 97207-1008
800 234-6006 or 503 684-6006, fax:503 684-6011

E. Patient and Family Support of SGD

The patient and her husband demonstrate motivation to maintain SGD. Have established basic skills with the LightWRITER. The patient understood the pros/cons of different devices and identified the LightWRITER as the optimal device for her needs.

F. Physician Involvement Statement

A copy of this report has been forwarded to the patient's treating physician (DR. … #XXX) on ______ (date) for review and prescription.

VI. TREATMENT PLAN

Upon receipt of SGD, it is recommend that the patient receive 45 minutes of individual therapy and one hour of group therapy weekly for 8 weeks (total 16 sessions). These sessions will address goals listed in Section IV of this report. An additional two hours of training are recommended to train caregivers to program the device.

V. SIGNATURES / SLP ASSURANCE OF FINANCIAL INDEPENDENCE

The Speech-Language Pathologist performing this evaluation is not an employee of and does not have a financial relationship with the supplier of the SGD.

____________________
XXX MS CCC-S
Speech Language Pathologist
ASHA #
State Lic.
Note: Signatures of other team members are not required by Medicare, but should be included when available.

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