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Pursuing funding for augmentative communication devices is not for the timid or the faint of heart.
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Unless you are working with a family who is very wealthy and can afford to purchase it themselves you need to be prepared for the paperwork & “fiery hoops”.
The funding department at the company selling the device will provide valuable support but a lot will rest on the shoulders of the SLP submitting the funding request.
It is wise to get as much information as you can before you start the process. Read through the definition of “medical necessity” and all the required elements for purchase of a speech generating device (SGD) as durable medical equipment (DME) for that insurance company and/or Medicaid in your state. This will give you both verbiage to include in your report and a checklist of all the bases you need to cover.
In my most recent funding request I had to deal with both the requirements of private insurance and Medicaid. Each had their own requirements. This patient’s insurance company required at least a 30 day trial with the SGD being requested. Medicaid in my state requires a video demonstrating clear communicative intent, independent use and for eye gaze devices “proof of accuracy”. Trying to submit a funding request before we had all of those elements would have been fruitless.
“Proving accuracy” may not sound like a big deal but I can testify that it was a huge fiery hoop when the patient was a 2.5 year old who had huge meltdowns every time I tried “show me the _____” activities. As in several sessions went down the toilet because we tried that.
So I laid in bed at night mulling over the quandary of how to “prove accuracy” in order to get her the AAC device that I knew she needed and that she had already shown me she could use. Add the extra self induced pressure of desperately wanting to get this accomplished before my retirement. Thank the Lord for stumbling upon a toy that this child was intrigued by. Not really the most highly preferred item. In fact early in the trial of the eye gaze device her Mom and I thought she may have been accidentally activating the button to request it since her reaction upon getting the toy was pretty “meh” 😐. So her Mom asked if I could move the button for it to a different location. Guess who immediately activated the button for that toy again and gave us her famous impish grin. Every time I moved that button she found it and grinned. So that was our golden ticket to making it through the fiery hoop of “proving accuracy”. I added a tiny button to her home page in Communicator 5 on the Tobii Dynavox i15+ eye gaze SGD and linked it to a page set that I built with the “noisy ball” and three other items with the placement randomized on each page. The first session I showed it to her she was a little fussy so we didn’t stay there long. The next week she was well rested and especially perky. Guess who found the “noisy ball” with 100% accuracy when presented in a playful way as a game of “hide and seek”? Yup. She did. And I got it all on video including her huge smile at the end as if to say “I rocked that didn’t I?”.
Tip: When you are required to provide a video with your funding request it’s important to always have a means of videoing on you in all sessions so you can capture the moments.
That was a huge fiery hoop to make it through and I worked late that evening to start the AAC eval report to get the funding request process started. Here’s the deal…. once you start that ball rolling you have to be willing to do what it takes under very short timeframes when they request additional video or ask for an addendum for additional information. If you don’t meet their very short timeframes then the request will automatically be denied and you have to start all over. For this child I had to provide documentation as to why she could not use handwriting as a means of communicating (ummmm…… not a developmentally appropriate expectation for any 3 year old let alone one with Rett Sydrome and no functional hand use) & additional videos proving she was making independent and intentional requests with the SGD. All of which had already been documented both in video and in writing. Of course I was frustrated every time but I had to vent to my fellow SLPeeps and then did what it took to make it through that next fiery hoop. I cried tears of relief and joy when I finally got the e-mail that her SGD had been approved and the day it arrived.
In the end it is all worth it to see the look on a child’s face when they get to take home their “voice” for the first time.
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I’m not sharing this to brag on myself but rather to leave pearls of wisdom learned from my 28 year career as a SLP. I’ll be retiring in 11 weeks so I’m trying to pass along things that I’ve learned before I move on to the next chapter in my life. I spent several hours researching the internet and posting in AAC and SLP Facebook groups begging for ideas for how to “prove accuracy” for a 2.5 years old using an eye gaze device. But there was nothing. So I hope that this info helps some other speechie in the future. For your patient it will likely be some other random toy or activity but the concept of turning it into a playful “hide and seek” activity may be your ticket to making it through the “proving accuracy” fiery hoop.
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Update 8/2/24: I just saw a post from our Tobii Dynavox rep in Oklahoma:
Amazing news!!
To Whom It May Concern,
Effective immediately the Oklahoma HealthCare Authority will no longer require a video to be submitted for review with a Prior Authorization requests for an AAC device.
Additional Info:
When you are completing your AAC evaluation report and funding request look it over to make sure that you documented the feature matching process, consideration of several options, trials of options and why that particular one is being recommended.
Most insurance companies are looking for justification for medical necessity and will only authorize funding of a requested SGD “that is not more costly than an alternative that is at least as likely to produce equivalent therapeutic results for the treatment of the plan member’s condition. Documentation must show that all least costly alternatives have been considered and ruled out before funding of an SGD will be authorized”.
Also referred to as the “least costly equally effective alternative”.
See this info on the PRC-Saltillo website for more info: https://www.prentrom.com/articles/least-costly-equally-effective-alternative?mode=view
Angela Moorad, MS, CCC-SLP, Founder of OMazing Kids, LLC OMazing Kids AAC Consulting
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