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Cognitive rehabilitation is a therapeutic approach designed to improve cognitive functioning after central nervous system insult. It includes an assembly of therapy methods that retrain or alleviate problems caused by deficits in attention, visual processing, language, memory, reasoning, problem solving, and executive functions. Cognitive rehabilitation consists of tasks designed to reinforce or re-establish previously learned patterns of behavior or to establish new compensatory mechanisms for impaired neurological systems. Cognitive rehabilitation may be performed by a physician, psychologist, or a physical, occupational, or speech therapist.
Cognitive rehabilitation must be distinguished from occupational therapy (CPT codes 97535-97537); occupational therapy describes rehabilitation that is directed at specific environments (i.e., home or work). In contrast, cognitive rehabilitation consists of tasks designed to develop memory, language, and reasoning skills that can then be applied to specific environments, as described by the occupational therapy codes.
Sensory integration and auditory integration therapy may be considered a component of cognitive rehabilitation and are addressed in the Sensory Integration Therapy and Auditory Integration Therapy medical policy.
Cognitive rehabilitation (as a distinct and definable component of the rehabilitation process) may be considered medically necessary in the rehabilitation of patients with cognitive impairment due to traumatic brain injury.
Cognitive rehabilitation (as a distinct and definable component of the rehabilitation process) is considered investigational for all other applications, including, but not limited to: stroke; post-encephalitic or post-encephalopathy patients; seizure disorders; multiple sclerosis; the aging population, including Alzheimer patients, and patients with cognitive deficits due to brain tumor or previous treatment for cancer and is not eligible for coverage.
Coverage of Applied Behavioral Analysis (ABA) for the treatment of autism spectrum disorder is addressed in the Treatment of Autism Spectrum Disorder (ASD) medical policy.
For services to be considered medically necessary, they must be provided by a qualified licensed professional and must be prescribed by the attending physician as part of the written care plan. In addition, there must be a potential for improvement (based on pre-injury function), and patients must be able to actively participate in the program. (Active participation requires sufficient cognitive function to understand and participate in the program, as well as adequate language expression and comprehension, ie, participants should not have severe aphasia.) Ongoing services are considered necessary only when there is demonstrated continued objective improvement in function.
Duration and intensity of cognitive rehabilitation therapy programs vary. One approach for comprehensive cognitive rehabilitation is a 16-week outpatient program comprising 5 hours of therapy daily for 4 days each week. In another approach, cognitive group treatment occurs for three 2-hour sessions weekly and three 1-hour individual sessions (total, 9 hours weekly). Cognitive rehabilitation programs for specific defects, eg, memory training, are less intensive and generally have 1 or 2 sessions (30 or 60 minutes) per week for 4 to 10 weeks.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
This policy is not intended to deny multidisciplinary services, such as physical therapy, occupational therapy, or speech therapy after traumatic brain injury and stroke.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
11/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/9/2001: "Policy Guidelines" section revised; "Code Reference" section updated
2/13/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
10/3/2002: Description section revised to be consistent with BCBSA policy, Lovaas Therapy for Autism and hyperlink to Sensory Integration Therapy added
11/27/2002: Sources updated
3/9/2004: CPT code 97770 deleted
4/19/2004: Policy reviewed, no changes
9/17/2004: Code Reference section updated, ICD-9 procedure code 93.89 added
5/1/2008: Policy reviewed, no changes
08/03/2010: Policy statement revised to state that cognitive rehabilitation may be considered medically necessary in the rehabilitation of patients with traumatic brain injury. All other indications remain investigational. Procedure codes 97532 and 93.89 moved from non-covered to covered. Added ICD-9 codes 854.00 - 854.19 as covered diagnoses. Deleted outdated references from the Sources section.
03/27/2012: Policy reviewed; no changes.
05/08/2013: Policy reviewed; no changes.
05/08/2014: Policy reviewed. Policy statement revised to add autism spectrum disorders and seizure disorders to the investigational policy statement for cognitive rehabilitation.
03/16/2015: Policy description updated regarding auditory integration therapy. Policy statement updated to state that coverage of Applied Behavioral Analysis (ABA) for the treatment of autism spectrum disorder is addressed in the Treatment of Autism Spectrum Disorder (ASD) medical policy. Added link to the Treatment of Autism Spectrum Disorder (ASD) medical policy. Deleted autism spectrum disorders from the investigational policy statement. Deleted the following policy statement: Lovaas therapy is considered investigational for treatment of autistic children.
08/25/2015: Code Reference section updated for ICD-10.
02/10/2016: Policy description updated to remove information regarding Lovaas therapy. Policy statement updated to clarify that cognitive rehabilitation may be considered medically necessary in the rehabilitation of patients with cognitive impairment due to traumatic brain injury. Policy statement updated to add multiple sclerosis and patients with cognitive deficits due to brain tumor or previous treatment for cancer as investigational. Policy guidelines updated to define active participation, add information regarding the duration and intensity of cognitive rehabilitation therapy programs, and to add medically necessary and investigative definitions.
Blue Cross Blue Shield Association policy # 8.03.10
This may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.