To clarify and give you an idea of how to generate an evaluation report, we have included a sample report for clients diagnosed with ALS for you to view. Please note that you need to customize this report to meet your specific needs.

A speech generating device (SGD) is covered when all of the following criteria (1-7) are met:

1. Prior to delivery of the SGD, the patient has had a formal evaluation of their cognitive and language abilities by a speech-language pathologist (SLP). The formal written evaluation must include, at minimum, the following elements:

• Current communication impairment, including the type, severity, language skills, cognitive ability, and anticipated course of the impairment.
• An assessment of whether the individual's daily communication needs could be met using other natural modes of communication.
• A description of the functional communication goals expected to be achieved and treatment options.
• Rationale for selection of a specific device and any accessories.
• Treatment plan that includes a training schedule for the selective device.
• Demonstration that the patient possesses the cognitive and physical abilities to effectively use the selected device and any accessories to communicate.
• For a subsequent upgrade to previously issued SGD, information regarding the functional benefit to the patient of the upgrade compared to the initially provided SGD and,

2. The patient's medical condition is one resulting in a severe expressive speech disability; and

3. The patient's speaking needs cannot be met using normal communication methods; and

4. Other forms of treatment have been considered and ruled out; and

5. The patient's speech disability will benefit from the device ordered; and

6. A copy of the SLP's written evaluation and recommendation have been forwarded to the patient's treating physician prior to ordering the device; and

7. The SLP performing the patient evaluation may not be an employee of or have a financial relationship with the supplier of the SGD.

Note: If one or more the SGD coverage criteria 1-7 is not met the SGD will be denied as not medically necessary.