Insurance Funding for AAC Devices: Instructions for SLPs - Test for Medicare Deference

Introduction:
Stated below is a two-step strategy intended to decrease "coverage based" insurance denials of AAC device funding requests: i.e., on the basis that AAC devices are "not covered." The strategy seeks to take advantage of the general practice by insurers of looking to Medicare's coverage or exclusion of types of treatment, including items of medical equipment, when they make their own coverage decisions under an insurance policy or benefits plan.

Procedure:
Step 1: As soon as possible after meeting the client, the SLP should make contact with the insurer to ask 2 questions about the insurer's reliance on Medicare DME coverage criteria. This contact may be made by telephone, but if it is, the substance of the conversation must be confirmed in writing. Or, the questions may be raised in a letter to the insurer.

Question 1: Do you look to, follow, rely on Medicare's DME coverage criteria when deciding funding requests for DME under the policy (or plan)?

Question 2: Do you use the Medicode HCPCS 2000, 2001, or 2002 manual as a reference for Medicare's coverage policies?

The second question asks whether the insurer uses (follows or relies on) a specific reference manual regarding DME as a guide to decision making. Specifically, the Medicode HCPCS 2000, 2001 or 2002 manual. This manual identifies specific items, such as items of DME, and reports on its coverage status by Medicare. As with the first question, the expected answer is "yes." The Medicode HCPCS manual is a very commonly used reference by insurance claims reviewers.

Step 2: If the insurer says yes to both questions, the SLP must prepare a letter to the insurer that addresses 3 points. This letter can be submitted as a cover letter with the SLP assessment report. The points to be made include:

1. Re-state, in writing, the two questions and the two answers. ("I asked you ..... You responded ....)
2. The SLP letter also must state the syllogism stated above: the insurer reports it follows Medicare; Medicare covers AAC devices as confirmed by NCD 60-23 and the RMRP for Speech Generating Devices; therefore, the insurer must cover AAC devices.
3. Third, the SLP letter must state that the Medicode HCPCS manual contains an error related to Medicare AAC device coverage. The manual continues to print the NCD for AAC devices that was withdrawn by Medicare in 2000 and replaced. This is an error, and the error has been acknowledged by the publisher of the Medicode HCPCS manual. A copy of a memo from the publisher [See attachment: H:/Newdirs/Taproj99/HCFA/medicode memo] must be attached to the SLP's letter.
4. The goal of this letter is to put the insurer on notice that it cannot, based on its own statements, deny an AAC device funding request on the basis of non-coverage.
5. In addition, by pointing out that the insurer's reference regarding what Medicare covers is wrong in regard to AAC devices, the SLP will be preventing a denial that may be based on reliance on incorrect Medicare guidance.

Questions about this procedure should be directed to the Assistive Technology Law Center, lgolinker@aol.com.

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