Alisa, I have successfully appealed decisions by writing letters that specifically state the justification for the recommendations you initially made. On one occasion we even did another short clinical trial to compare devices, which we documented in the letter. I have used the following wording successfully:

Clinical trials were conducted (for ...) as part of a comprehensive evaluation for SGD replacement. Device features were compared with consideration for ___’s specific cognitive, motor, linguistic, communication and access needs.
The following SGDs were initially considered ...
determined that the ___(SGD) is most appropriate
No other SGD considered for ___offers this feature
The ___(SGD) is unique  in that it provides/offers...
features of the xxxx language system provide the fastest and most efficient communication using scanning and make it most adequate for meeting ___s daily functional communication needs.
Features unique to the ___ are not available in any of the other SGDs considered.  
the XXX did not offer patient new features that are crucial for motor/physical access to vocabulary
Given ___’s ___ level of linguistic functioning (or motor, or visual etc.), this language system supports communication needs now & in the future.
xxx and xxx SGDs differ with regard to software (vocabulary organization) features that are crucial for meeting xxx’s unique motor/access needs. 
In contrast, the xxx SGD provides access to an extended vocabularycalled xxx that is most adequate for meeting xxx’s unique access needs using (single switch) scanning for the following reasons: (list each feature and directly compare to the other SGD stating why one is appropriate and why the other is not adequate)
The (other SGDs) vocabulary organization is inadequate for meeting the needs of ...
In response to being told we were asking for a "fancier device" than deemed necessary we responded: As with all durable medical equipment, upgrades to SGDs are common and usual practice and represent enhanced and improved versions of hardware and software. Recommendations for upgraded versions of equipment are not requests for a “fancier” SGD.  Rather, upgraded versions of SGDs are released regularly by manufacturers and provide improvements in functional use for the patients who use them daily.

It seems that if you can justify the SGD primarily with regard to access it will go through.

I think we need to educate the insurance carriers that "one size does not fit all". We are comparing these devices with regard to the hardware and the software (vocab organization system) which impact motor/access, sensory, linguisitc & cognitive domains.

good luck!
Judith



Judith Lunger-Bergh, M.A., CCC-SLP
Speech/Language Therapy Services
2550 9th Street Suite 115
Berkeley, CA 94710
OF: 510-845-7510
H/OF: 925-254-1723



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