LETTERHEAD FROM YOUR INSTITUTION

(Date)

Re: (individual's name)
DOB: (individual's date of birth)
Any other identifying names or number: DSHS PIC #, subscriber id, etc.

Dear Medical Consultants:

[In your introductory paragraph be sure include the following information in paragraph (not bulleted) form:
·* Who request is for (use that name in place of XXX below)
·* What you are requesting: which ACD is requested.
·* Single statement that XXX needs it for health and safety reasons as discussed below.

Background on the individual:
[In the next section you can use bullets to give the following info:
·    Age:
     Medical diagnosis:
·    Speech diagnosis:
·    Prognosis for improvement of speech:
·    Motor control of arms and legs:
     Hearing:
·    Vision (for AAC):
     Significant surgeries:
·    Other Adaptive Equipment: (Here list all equipment owned by the individual. If there is a wheelchair, you must include make, model, serial number, vendor name)

Medical justification for ACD:
[NOTE: This section will be most meaninful if you already understand the concept of "Medical Necessity" as applied to AAC by Washington State payers. Details are available on this website in Funding Terminology to Know.]

In this section, we write about two very specific incidents that have already happened in which this individual's health and safety were jeopardized by the inability to communicate. They must be circumstances where the use of a device would have prevented the problem (so, for example, you cannot use seizures or near drowning, since no one can use a device during a seizure or in the water). Also they must be circumstances for which this individual already has the ability to use the device (so you cannot use some elaborate language or vocabulary that this child could not do independently after initial training on this device.)

For this purpose consider the following:
* trips to the emergency room that could have been avoided
* injuries or near injuries that could have been avoided
* medical conditions that make injuries likely without communication
* medical tests that could have been avoided through communication)

NOTE: Make sure you AVOID any references to the use of communication for educational purposes at school (although medical and emergency communication at school is fine). This would make the medical payer refuse the request and recommend school funding.]

Motor access to ACD:
[NOTE: we describe the motor access method that we are recommending and why it is most appropriate. We do not have to state all the access methods that this individual cannot use, since that is covered below. We then summarize with the only type of access that is appropriate.]

Decision-making based on device features:
[NOTE: This section requires familiarity with the concept of device "features" as described elsewhere on this website. If you write a letter without understanding device features, you will jeopardize your request because this is the way that payers make decisions.. We recommend that you do not proceed without that understanding. For more information on this approach, see AAC Equipment Features]

[ Some third party payers request information about "equipment trials" as if that is how decisions are made. However, it is our strong opinion that trials with an communication device should not be the PRIMARY focus for decision-making for two reasons: 1) just because someone can use a device does not mean it will meet their needs; and 2) there are simply too many devices to conduct trials on each one. Trials ARE appropriate (and it is reasonable for any third party payer to request evidence of successful trials) but only with a sub-set of devices that might meet the individual's needs.]

[In our letters of justification, we try to show the reasoning behind the decision-making, using a "feature-based approach" to the devices. This means we need to understand the specific features or components of each device and use them to rule out devices that won't work for this individual and, eventually, to narrow the field to the ONE device that is appropriate.]

It has been our experience over the years that third party payers respond to this feature-based approach. Some of them, particularly DSHS, have a great deal of information about the most commonly used devices in Washington State (though they do not necessarily have current information about the device you are recommending.). If you do not think in terms of components or features of the devices, they will do it for you, usually selecting the least expensive device that has the features you've identified as necessary.

For these reasons, we use features of devices to rule out devices one by one until we get to the one that we are recommending. You do not have to rule out every single device that is available, but the more thorough you are, the fewer problems you will have with DSHS. Here are some examples, but note that these are for all possible individuals (they will sound terribly inconsistent if you think it is just one child). All these reasons have been used in the past and should be familiar to local payers.]

1. Devices accessed via direct selection because XXX has inadequate motor control for this method of access. This rules out, for example, all of the following devices: VoiceMates, Talk Ease, Talk Back, Black Hawk, Abovo, Crestalk, Attainment Talkers, MessageMates etc.

2. Devices based solely on letter-by-letter spelling, because XXX cannot spell well enough yet to meet all communication needs for medical necessity. This rules out all devices based primarily on spelling, including: Canon Communicator, LightWriter, etc.

3. Devices with vocabulary accessible via paper overlays because XXX cannot physically change overlays. This rules out, for example: Holly.com, DigiVox (with levels), Macaw (with levels), AlphaTalker (with levels), Tech/Speak, etc.

4. Devices with limited vocabulary capacity because XXX needs more words/phrases to meet all medical and physical needs (see medical justification above). You must then list the devices that have vocabulary that would be insufficient.

5. Devices without auditory scanning capability because [NOTE: here we use several different reasons: 1) XXX cannot always keep his head forward to look at the screen due to his extremely severe asymmetrical tonic neck reflex. When he cannot face the screen, he can utilize auditory cueing to know where the scanning cursor is positioned. or 2) XXX has significant vision impairments that preclude reliance on visual symbols, etc.} These cues must be delivered via a separate speaker so the message output is clear. This rules out, for example: Communication Station, DynaVox I.

6. Devices with only synthesized speech because XXX must have voice output in the (YYY) language in order to communicate with his immediate family. (NOTE: this language cannot be any of the common languages for which there is synthesized speech available.) At this time, this is only possible via digitized speech. This rules out, for example: Hawk family of products

7. Devices that rely on encoding for message storage and retrieval because XXX has demonstrated an inability to learn the sequencing of the codes for proper retrieval. (NOTE: you must rule this one out very carefully. There are many individuals who can do this encoding and for whom encoding is far more appropriate than other retrieval methods.) This rules out, for example: AlphaTalker, DeltaTalker, Liberator and other systems based solely on encoding.

8. Devices which are unreliable due to mechanical failures or frequent software bugs because XXX's health and well being will be jeopardized each time the device requires repair. This rules out, in our experience:

9. Devices that would be difficult to use or maintain because this individual (or the caregivers) are uncomfortable with complex technology. This rules out:

[NOTE: once we have used this component approach to rule out most, if not all, less expensive devices, we then name the device we are recommending and justify it by listing its essential features:

In summary, the only device that will meet XXX's needs for communication is the __________, manufactured by _____________. This is the only device on the market that __________________.

Cognitive ability to utilize recommended ACD:
[NOTE: Here we describe the individual's success using the recommended device for functional communication. Describe when and where trials took place along with any other evidence of cognitive ability.]

Therapy:
[Some third party payers require a brief history of OT, PT and Speech therapy, particularly for children. We give a very brief synopsis of the past, if available, but more detail about current therapies, including duration and frequency of each type.]

Justification for each piece of equipment:
These trials and the reasoning above have led us to conclude that the only device that will meet XXX's needs is the ____________. In addition, XXX will need some peripheral equipment for the following reasons:

[NOTE: every single piece of equipment must be justified with a specific reason why it is necessary for him/her to run the device that has been recommended. If you leave out a piece of equipment, it will delay the approval or result in a denial of that equipment].

Expectations with ACD:
[NOTE: Some third party payers ask you to list what communication functions (from the following list) the individual will be able to do with this device and in what time period. Only include the things that you believe he/she can accomplish in the time you specify given sufficient support with the device.]
1) communicate with a personal physician about a medical condition, complaint, ailment or symptoms.
2) communicate with personal caregivers about both urgent medical needs and routine personal care needs
3) develop improved expressive communications skills, vocabulary and understanding
4) attain specific speech therapy goals and objectives according to the speech treatment or training plan.

NOTE: Again, make sure you AVOID any references to the use of communication for educational purposes or at school. This would make the payer refuse the request and recommend school funding.

Plan of care for the ACD:
[NOTE: Some third party payers want to see a plan for the following implementation steps. It appears that this information may be more critical in requests on behalf of children than in requests for adults. You may choose to name the individuals or leave them described by position only (e.g. SLP) but you must indicate who will be doing what.]

· Initial Programming and Training:
· On-Going Programming:
· Quarterly consultation:
· Yearly re-evaluation:

Team expertise in AAC:
[NOTE: This is the place to explain YOUR TEAM's EXPERTISE with AAC. Include individuals' names, credentials, AAC coursework/workshops/presentations you've attended, years you have served AAC clients, courses/workshops/presentations that you have given in AAC, and any other experience that you feel is relevant to your expertise.]

[NOTE: Make sure you thank them for considering this request!]

[Closing: e.g Sincerely,]

[Signatures and titles. Although it is generally advisable to have a physician co-sign this letter, you do not have to do so as long as he/she signs a prescription that is attached. However, this letter must be signed by an SLP and an OT. If an OT is not necessary because there are no motor impairments, that must be explained earlier in the letter.]

[NOTE: add in cc's and Enclosures: Make sure to enclose all necessary forms as deemed by the manufacturer and/or by the third party payer. This letter is incomplete without those forms! See details about these enclosures on this website at Funding AAC in Washington State.]

[NOTE: Mailing: Some manufacturers require that you mail this documentation directly to them and they then forward it on to the payer with a current cost estimate. You must discuss this with the company's representative before mailing the packet.]