When My Client Needs a New Device…

Posted on January 11, 2012

What are the Medicare guidelines for replacement or upgrades to a new Speech Generating Device (SGD) when my client’s device is old and no longer functional? When researching this question, I found the website, AACFundingHelp.com, an informational website about SGD Funding Solutions from the Assistive Technology Law Center, to be a very valuable resource. In it I found a very thorough discussion of many aspects of this question that speech language pathologists should consider.

According to the website, AACFundingHelp.com, it is important that all speech language pathologists understand how Medicare uses the term “replacement.” In the Medicare world, “replacement” is defined as “the provision of an identical or nearly identical item.” This does include any substitute of a new item for an existing one, whether the new one is the same or different model type. In an attempt to interpret this definition, it is necessary to understand that Medicare does not include in their narrow view of this word “replacement”, any circumstance or situation in which a person’s medical condition has changed and they are therefore requiring a different SGD.

Under Medicare guidelines, there are certain circumstances that do indeed necessitate a replacement device (unlike the change in medical condition situation mentioned above that technically does not fall under the Medicare definition of replacement). The situations included in this definition are when a device has suffered “irreparable damage” or when there has been “irreparable wear” sustained by the day to day use of the device.

How do we understand the difference between irreparable damage and irreparable wear as used in the Medicare definition? Again, I turned to the website AACFundingHelp.com to help me sort this out. Irreparable damage, to Medicare, refers to a specific accident or natural disaster that renders the device unusable due to damage. Irreparable wear, on the other hand, refers to the “deterioration sustained by day-to-day usage over time and a specific event cannot be indentified that rendered the device unusable.”

When considering replacement of a device for irreparable wear, Medicare takes into account the “expected useful life” of the device. Medicare guidelines state, “if the item has been in continuous use by the patient for the equipment’s useful lifetime, the user may elect to obtain a new piece of equipment.” Medicare does not impose any time frame on this definition of “useful lifetime”, but rather leaves it up to the DMERC’s (Durable Medical Equipment Regional Carrier – or the private company with which all claims for durable medical equipment is submitted) to make that determination themselves. However, the DMERC’s are instructed by Medicare that this timeframe is to be “no less than 5 years.” That explains the 5 year rule that Medicare appears to have with regard to replacement of equipment that wears out or becomes unusable due to daily use. In contrast, if a specific event can be identified that is the cause of “irreparable damage”, e.g. the device is lost in flooded house, this “5 year rule” does not apply. However, it is important to note, that “replacement” according to Medicare, means replacement of the same model. When a model has gone out of production, replacement of the current device will be with the device that succeeds the earlier model.

In summary, it is important to understand that the term “replacement” does not apply in situations where the client’s medical condition has changed and they are no longer able to use their existing SGD. It is also important to differentiate between irreparable wear and irreparable damage which will be helpful in understanding when you are able to make a request for the replacement equipment.

Submitted by Medicare Report Reviewer, Beth Studdiford, M.S., CCC-SLP