Is your client considering upgrading to a new device? Here are some questions you can ask and considerations to be made when making a request for a new device:
Before considering replacement:
- Has the device been repaired? If so, is there a record of repairs?
- Is the device beyond repair? If so, how old is the client’s current device?
- Who is the client’s funding source?
- Does the client’s funding source have a rule regarding the expected useful lifespan of an SGD?
Many funding sources require that the client’s current device reaches a certain age or an expected useful lifespan of a certain number of years before a replacement device will be considered for the client. Medicare and many other funding sources expect that an SGD will last 5 years before a replacement will be necessary. Some funding sources place the useful life age limit of a device at 3 years before replacement consideration. When you have a client, who would like to replace or upgrade to a new device, for any reason, it is very important that it is determined if the funding source has an expected useful lifetime limit, and if there are rules for making a request for a new device prior to the device reaching that limit.
There are situations under which replacement prior to the expiration of the useful life of the device will be considered by funding sources. Some examples include a change in the client’s medical status that requires features not available on the client’s current device to meet the client’s daily and medical communication needs, or if there has been an incident that caused irreparable damage to the client’s device.
The following points are Medicare considerations for requests for devices prior expiration of the expected useful lifespan of 5 years:
- Medicare closely scrutinizes requests for devices received prior to 5 years. Per Medicare guidelines, in order to receive a device replacement prior to the 5 year mark, the documentation must support one of the following (as found on the following website):
- Whenever it no longer meets your needs, because your needs have changed. Note: if your needs change, e.g., a progressive impairment progresses and you can't use the existing stuff, you can change it at any time. But, the expectation is that you need something in a new code. If you need an accessory, no problem -- change of condition is enough. No time issues there. But if you need a whole new box, then you have to show change of condition, and a change of code to get around any question of timing.
- Whenever it no longer works, if the reason it does not work can be attributable to a specific cause (irreparable damage is a specialized term, to Medicare it refers to a specific accident or to a natural disaster, e.g. a fire, flood, etc.).
- After 5 years if it does not work due to ordinary wear and tear. whenever it no longer meets your needs, because your needs have changed. Note: if your needs change, e.g., a progressive impairment progresses and you can't use the existing stuff, you can change it at any time…but, the expectation is that you need something in a new code. If you need an accessory, no problem -- change of condition is enough. No time issues there. But if you need a whole new box, then you have to show change of condition, and a change of code to get around any question of timing.
- Regarding Irreparable Wear: Medicare also describes a different circumstance that necessitates replacement: irreparable wear. This is defined as "deterioration sustained by day-to-day usage over time and a specific event cannot be identified." For devices sought to be replaced for this cause, Medicare will take into account an expected useful life of the product. Medicare states "if the item has been in continuous use by the patient" for the equipment's useful lifetime, the beneficiary may elect to obtain a new piece of equipment. Medicare guidance also states that the reasonable useful lifetime of DME is to be set by program instructions. To date, none has been written for SGDs. For this reason, the DMERCs are instructed to make this determination themselves, "but in no case can it be less than 5 years." This guidance is important regarding the so-called "5-year rule." Medicare appears to have a "5-year rule" for replacement of equipment that simply wears out and becomes irreparable due to daily wear and tear. By contrast, when a specific event can be identified as the cause of the irreparable damage to the device, e.g., it is dropped, the 5-year rule does not apply. A device whose status as irreparable can be traced to a specific event, can be replaced whenever it is determined to be irreparable.
When making the case for the medical necessity of a new device prior to the expected useful lifespan limit of the device as per the funding source, it is important to provide thorough documentation that supports the client’s need for a new device. The following are some considerations of what you should include in your SGD report when requesting a new device for your client:
- A repair record establishing that the device has been repaired or attempts have been made to repair the device. It is important to show the funding source that the device has been problematic for the client and that repairs or repair attempts have been made. If the client, client’s family or caregivers don’t possess this record, it is often possible to get the repair record from the service department of the SGD company.
- If your client has had a change in medical status that requires a new device, include discussion, data, and evidence that show that the client’s current device is not meeting his/her daily and medical needs, compared to the recommended/requested device. Discuss the client’s change in medical status and how it has impacted his/her communication. Show through data and evidence that the client can no longer use his/her current device, but rather requires features on the recommended/requested device to meet his/her daily needs.
- If there has been an incident causing irreparable damage to the client’s current device, include a detailed discussion of this event, as well as impact on the client of being without communication.
- If the device is damaged as a result of a fire, you should include a fire report with all documentation submitted.
- If the device is lost or stolen, a police report should be filed and included with all documentation submitted.
- Data is very important when making a request for a device prior to its expected useful lifespan. If the client’s current device is still operational, comparative data of the recommended new device to the client’s current or old device such as client’s access rate, accuracy of message formulation, number of utterances generated, type of utterance generated, or some examples of potential data that can be gathered and shared in the report.