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Cognitive rehabilitation (CR) 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. CR 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 integrative therapy may be considered a component of cognitive rehabilitation. However, sensory integration therapy is addressed in a separate policy.
Lovaas therapy is an intensive behavioral treatment program that attempts to improve the cognitive and social functioning of children with autism.
Cognitive rehabilitation (as a distinct and definable component of the rehabilitation process) may be considered medically necessary in the rehabilitation of patients with 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; autism spectrum disorders; seizure disorders; and the aging population, including Alzheimer patients and is not eligible for coverage.
Lovaas therapy is considered investigational for treatment of autistic children.
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. Ongoing services are considered necessary only when there is demonstrated continued objective improvement in function.
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
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.
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.