2.2.4.3

Prior Authorization

Prior authorization is required for ACD systems provided through Home Health Services. The prior authorization also includes all related accessories and supplies. The physician must provide information supporting the medical necessity of the equipment or supplies requested, including:

•	Accurate diagnostic information pertaining to the underlying diagnosis or condition and any other medical diagnoses or conditions, including the client’s overall physical and cognitive limitations.

•	Diagnosis or condition causing the impairment of speech.

Prior authorization for an ACD system and accessories (rental or purchase) must be requested using the following information:

•	Medical diagnosis and how it relates to the client’s communication needs.

•	Any significant medical information pertinent to ACD system use.

•	Limitations of the client’s current communication abilities, systems, and devices.

•	Statement as to why the prescribed ACD system is the most effective, including a comparison of benefits using other alternatives.

•	Complete description of the ACD system with all accessories, components, mounting devices, or modifications necessary for client use (must include manufacturer’s name, model number, and retail price).

•	Documentation that the client is mentally, emotionally, and physically capable of operating the device.

•	An evaluation and assessment must be conducted by a licensed SLP in conjunction with other disciplines, such as physical or occupational therapies. The prescribing physician must base the prescription on the professional evaluation and assessment.

The prior authorization request must include the specifications for the ACD system, all component accessories necessary for the proper use of the ACD, and all necessary therapies or training. It is recommended that the preliminary evaluation for an ACD system include the involvement of an occupational therapist or physical therapist to address the client’s seating/postural needs and the motor skills required to utilize the ACD system.

The prescribing physician familiar with the client must review the SLP evaluation of the client’s cognitive and language abilities and base the prescription and treatment plan on the SLP’s recommendations.

An evaluation and assessment by a licensed SLP must be signed and dated before the date on the physician’s prescription or the Title XIX form and include the following information:

•	Documentation of medical necessity for an ACD system, including a formal written evaluation performed by a licensed SLP.

•	Medical status or condition and medical diagnoses underlying the client’s expressive speech-language disorder that justifies the need for an ACD system.

•	Current expressive speech-language disorder, including the type, severity, anticipated course, and present language skills.

•	Description of the practical limitations of the client’s current aided and unaided modes of communication.

•	Other forms of therapy or intervention that have been considered and ruled out.

•	Rationale for the recommended ACD system and each accessory, including a statement as to why the recommended device is the most appropriate and least costly alternative for the client and how the recommended system will benefit the client.

•	Documentation that the client possesses the cognitive and physical abilities to use the recommended system.

•	Comprehensive description of how the ACD system will be integrated into the client’s everyday life, including home, school, or work.

•	Treatment plan that includes training in the basic operation of the recommended ACD system necessary to ensure optimal use by the client (if appropriate, the client’s caregiver) and a therapy schedule for the client to gain proficiency in using the ACD system.

•	Description of the client’s speech-language goals and how the recommended ACD system will assist the client in achieving these goals.

•	Description of the anticipated changes, modifications, or upgrades with projected time frames of the ACD system necessary to meet the client’s short- and long-term speech-language needs.

•	Identification of the assistance or support needed by, and available to, the client to use and maintain the ACD system.

•	Statement that the licensed SLP is financially independent of the ACD system manufacturer/vendor.

•	Speech- and language- skills assessment that includes the prognosis for speech or written communication.

•	Interactional/behavioral and social abilities.

•	Capabilities, including intellectual, postural, sensory (visual and auditory), and physical status.

•	Motivation to communicate.

•	Residential, vocational, and educational setting.

•	Alternative ACD system considered with comparison of capabilities.

•	Ability to meet projected communication needs, growth potential, and length of time it will meet the client’s needs.