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Hi Alisa- One more thing- In terms of the appeal, if Medicare is saying that it is not
medically necessary, then the appeal should be crafted to show why it is
medically necessary. Even though Medicare is saying that the person
can keep
repeating themselves, the reality is I’m sure we have all seen
clients who just
gave up on speaking because it was too tiring, or because they had to keep
repeating themselves. I’ve seen many clients who, if they
weren’t understood
the first time, would just say “forget it”. For
most clients, it’s just not
functional to repeat 1/3 of what they say. I think it’s also important to demonstrate how the
person’s
speech is not functional in certain situations (i.e. over the phone, with
certain caregivers, at night, in the car, etc.) I think it’s also important to look at medical
necessity in
terms of rate of progression. If a person has a certain speech rate,
we know
that the machine is going to be needed by the time that they receive it.
(Although, at 70% intelligibility, it sounds like the person probably needs
it
now.) Margaret
Cotts From:
xxxxxx@xxxxxxxxxxxxxxxxxxxx
[mailto:xxxxxx@xxxxxxxxxxxxxxxxxxxx] On Behalf Of Alisa
Brownlee Hi everyone, I am asking for feeback on the following information
that I
was given from a funding coordinator at Dynavox today. I have her
permission to ask the group for their reactions and to see if this is
happening
with some of your submissions for SGD funding. Problem is with Medicare and not funding a device based
on a
client's intelligibility. Upon correspondence with this funding
person, she informed me of a recent denial from Medicare that I have
attached. (SLP documented that the person with ALS had a 70%
intelligibility) The denial letter indicates that since this person
can
still make themselves verbally understood, they don't qualify for an
SGD.
Anyone have denials like this??? I am not sure what type of wording we need to use now
because
if CMS is considering the fact that someone can still make themselves
verbally
understood, regardless of fatigue or dysarthria, then when is someone to
use an
SGD?? When they have no vocalizations at all?? Feedback appreciated.... Thanks, Alisa Alisa
Brownlee, ATP Assistive
Technology Consultant, ALS Association, National
Office
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