Letter of Medical Necessity (AAC Device)

Date: [Date of letter]
To: [Payer/plan name], [Utilization Management Department address or fax if known]
Re: Patient Information
- Patient full legal name: [Patient full legal name]
- Date of birth: [DOB]
- Member/Subscriber ID: [Member/Subscriber ID / Not available at time of letter]
- Policy/Group number: [Policy/Group number / Not documented]
Request Type: [initial device request / replacement / upgrade / accessory-only / software-only]
Requested Device: [Device name], [Manufacturer], [Model], [HCPCS code(s) if known / See attached vendor quote]
Prescribing Practitioner: [Name, credentials], [NPI if available], [Practice name]
Evaluating SLP: [Name, credentials], [License number and issuing state], [NPI if available], [Facility]

Dear [Utilization Management Reviewer / Medical Director / To Whom It May Concern]:

Medical Necessity Summary

[Executive summary paragraph] (Compose 4–8 concise sentences in plain language for a non-clinical reviewer, covering: (1) a one-sentence clinical problem statement describing the severe expressive communication impairment; (2) functional impact on daily life, including difficulty communicating basic needs, medical symptoms, and safety concerns; (3) the requested solution: a dedicated speech-generating device and the specific access method; (4) why natural speech and lower-tech options are insufficient; and (5) anticipated outcomes with confirmation that a training plan is in place.)

Clinical Background and Diagnoses

[Brief clinical context summary] (Provide relevant history that directly impacts communication or device selection. Omit unrelated history. If ICD-10 codes are not confirmed in the record, reference attached documentation rather than guessing. If any required information is unavailable, write "Not documented" or "See attached records.")

• Primary diagnosis driving speech impairment: [Diagnosis name], [ICD-10 code if documented / See attached records]
• Secondary diagnoses/comorbidities affecting access or use: [Motor / vision / hearing / cognition / fatigue / progressive disease], [ICD-10 codes if documented / See attached records]
• Onset, course, and prognosis: [Onset], [Stable / Improving / Progressive]
• Relevant therapy or medical history: [Therapies tried, surgeries, hospitalizations, or factors directly affecting communication function and access]

Current Communication Profile and Functional Limitations

• Expressive communication impairment: [Type and severity] (Include objective measures when available, such as intelligibility percentages or standardized functional communication ratings.)
• Current communication methods and reliability: [Natural speech / gestures / sign / writing / communication boards / partner interpretation] (Describe accuracy, speed, fatigue, and consistency across partners and environments.)
• Receptive language and cognition: [Relevant receptive language abilities and cognitive factors that support device use]
• Functional limitations: [Difficulties communicating basic needs (pain, toileting, hunger), reporting medical symptoms, emergency communication, communicating with unfamiliar partners, and communication across home/community/medical settings]
• Independence: [Statement on whether the patient can generate messages independently or requires partner support and in what contexts]

Concrete examples of communication breakdowns and consequences:

• [Example 1: Brief description of breakdown and consequence]
• [Example 2: Brief description of breakdown and consequence]
• [Additional examples if applicable]

Alternatives Considered

• Natural communication options: [Speech / gestures / sign / writing] — [Specific barriers and why insufficient]
• Low-tech AAC: [Communication boards / picture systems] — [Why insufficient]
• Trials and results: [What was trialed], [Dates], [Duration], [Results and observed benefits/limitations] (If formal trials were not conducted, clearly state the reason.)

AAC Evaluation Summary

[Evaluation dates and setting] (Confirm face-to-face evaluation when applicable.) [Evaluator credentials]. [Statement of no employment or financial relationship with the device supplier.] [Assessment approach: feature-matching, dynamic assessment, device/app trials.] [Patient capabilities: cognitive/linguistic level (symbol vs text), motor access method, sensory considerations.] [Communication partners and environments assessed.] [Confirmation that a treatment plan and training schedule exist.] (Reference attached evaluation report for full data; do not include full scoring tables here.)

Recommended Device and Feature-to-Need Mapping

Base device recommendation: [Manufacturer], [Model], [Device category]
Access method: [Direct selection / switch scanning / eye gaze / head tracking / other] — [Rationale linking motor/sensory needs to access method]

(Map each functional limitation to a specific medically necessary device feature or accessory and the expected outcome. Include rows for all requested features, accessories, and mounting equipment. Each item must have its own medical necessity statement.)

Functional Limitation/Need	Required Device Feature/Accessory	Expected Outcome
[Limitation/Need 1]	[Feature/Accessory 1 with brief rationale]	[Outcome 1]
[Limitation/Need 2]	[Feature/Accessory 2 with brief rationale]	[Outcome 2]
[Limitation/Need 3]	[Feature/Accessory 3 with brief rationale]	[Outcome 3]
[Additional rows as needed for each requested item]	[Feature/Accessory with rationale]	[Expected outcome]

Scope of request: The requested configuration is limited to medically necessary speech-generating communication functions and excludes general computing or convenience features.

Equipment Request List

Base Device

• [Item name, manufacturer, model/product number] — [HCPCS code if known] — Qty: [#] — [One-sentence medical necessity rationale]

Accessories and Mounting

• [Accessory 1: name, manufacturer, model/product number] — [HCPCS code if known] — Qty: [#] — [One-sentence medical necessity rationale]
• [Accessory 2: name, manufacturer, model/product number] — [HCPCS code if known] — Qty: [#] — [One-sentence medical necessity rationale]
• [Additional items as needed]

Training Plan and Expected Outcomes

Training Plan

• Participants: [Patient], [Caregivers], [Communication partners]
• Frequency and duration: [Sessions per week], [Session length], [Total duration]
• Content areas: [Device operation], [Vocabulary/message generation], [Partner training], [Vocabulary customization], [Access method calibration]
• Outcome monitoring: [Progress measures and review intervals]

Expected Outcomes (List 3–6 measurable goals tied to medical communication needs. Include time horizon, baseline, and measurable criterion.)

• [Goal 1: By [timeframe], from baseline of [baseline], patient will [functional speaking task] with [measurable criterion] using the SGD.]
• [Goal 2: By [timeframe], patient will communicate medical symptoms/pain using the SGD with [accuracy/independence criterion].]
• [Goal 3: By [timeframe], patient will initiate safety/emergency messages using the SGD within [time/accuracy criterion].]
• [Additional goals as applicable]

Compliance Attestations

• The patient has a severe expressive speech impairment requiring AAC to meet functional speaking needs.
• Alternative communication methods were considered and are insufficient to meet the patient's medically necessary communication needs.
• The AAC evaluation was completed by a qualified SLP, and supporting documentation is attached.
• The SLP has no employment or financial relationship with the device supplier.
• The evaluation findings and recommendation were provided to the treating practitioner for review.
• The requested configuration is limited to medically necessary speech-generating communication functions.

Attachments

• Full AAC evaluation report
• Prescription/standard written order
• Trial logs (if performed)
• Vendor quote (if required)
• Supporting clinical documentation
• Letters from other disciplines supporting access needs (if applicable)

Signatures

Sincerely,

SLP Signature: ________________________________ Date: ___________
Printed Name/Credentials: [Name, credentials]
License Number/State: [License number and state]
NPI: [NPI if available]
Contact: [Phone], [Fax], [Email]

Treating Practitioner Cosignature (if required by payer): ________________________________ Date: ___________
Printed Name/Credentials: [Name, credentials]
NPI: [NPI if available]

Facility: [Facility name]
Address: [Street address, City, State, ZIP]
Phone: [Phone] | Fax: [Fax] | Email: [Email]

(Do not use stamped signatures if prohibited by payer. Do not backdate.)