Clinical Medical Policy Cognitive Rehabilitation

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1 Benefit Coverage Outpatient cognitive rehabilitation is considered to be the most appropriate setting for members who have sustained a traumatic brain injury or an acute brain insult. Covered Benefit for all Lines of Business including Rhody Health Options (RHO) Phase I, Rhody Health Expansion (RHE), and Health Benefit Exchange (HBE), excluded from Benefit Extended Family Planning (EFP) Cognitive rehabilitation may be performed individually, in groups, or both, depending upon the needs of the individual and may include intensive therapy by speech-language pathologists, physical therapists, occupational therapists, and neuropsychologists. Vocational rehabilitation is not a covered benefit for RIte Care and Rhody Health Partners members. If this is the primary focus of a cognitive rehabilitation program then coverage will not be provided. Cognitive rehabilitation comprises a variety of therapeutic activities that are designed to retrain an individual s ability to think and use judgment to make decisions. The techniques used for cognitive rehabilitation attempt to help a patient to reduce, manage, or cope with the cognitive deficits caused by brain injury and may include learning how to do things differently when functions cannot be restored to the pre-injury level. Criteria All the following criteria must be met to qualify for cognitive rehabilitation: 1. Dx: TBI, acute brain insult, or acute CVA (see Appendix A). 2. The service must be ordered by the attending physician and be part of a written plan of care 3. Individual is capable of actively participating and willing to participate in treatment plan. 4. Documented potential to show measurable functional gains within a predetermined timeframe. 5. History of compliance with treatment plan. 6. The individual's mental and physical condition prior to the injury indicates there is significant potential for improvement and the individual must have no lasting or major treatment impediment that prevents progress, such as severe dementia. 7. In the presence of a recent or current history of unresolved behavioral health issues or substance abuse, an active treatment program with demonstrated compliance is an integral part of the proposed cognitive rehab program. 8. Viable discharge placement alternatives are identified during the assessment for admission to the program. 9. The treating physician should review the treatment plan to assess the continued need for participation and documented objective evidence of progress. When cognitive rehabilitation is performed by a physical, occupational and/or speech therapist as part of the outpatient rehabilitation /therapy program for patients who are eligible, these services will be counted toward any applicable therapy visit limits. Inpatient Programs All of the above criteria must be met as well as the following: 1. Constant supervision required 24/7 due to poor judgment and safety concerns. 2. An alternative level of care cannot provide the intensity of services required for the treatment of the cognitive deficits. 1

2 Continued Treatment for All of the following criteria must be met to extend authorization of a cognitive rehabilitation program: 1. Established interim goals are met. 2. Member demonstrates quantifiable rates of improvement on functional abilities. 3. Evidence of compliance ability, willingness, and active participation in treatment program. 4. An alternative level of care cannot provide the intensity of services required for the treatment of the cognitive deficits. Exclusions There is insufficient evidence in the published medical literature to support the use of cognitive rehabilitation for any condition other than traumatic brain injury, acute brain insult, or CVA. See Appendix B. Coma stimulation is unproven and considered not medically necessary for the treatment of comatose or minimally responsive patients who have sustained a brain injury due to lack of sufficient evidence. Appendix A (Note: This list of codes may not be all inclusive) ICD-9-CM Covered Diagnosis Codes Post-concussion syndrome Intracranial abscess Anoxic brain damage Toxic encephalopathy 430 Subarachnoid hemorrhage 431 Intracerebral hemorrhage Cerebral thrombosis with cerebral infarction Cerebral embolism with cerebral infarction Unspecified cerebral artery occlusion with cerebral infarction Late effects of cerebrovascular disease; cognitive deficits Fracture of vault of skull, closed Fracture of vault of skull, open Fracture of base of skull, closed Fracture of base of skull, open Other and unqualified skull fracture, closed 2

3 ICD-9-CM Covered Diagnosis Codes Other and unqualified skull fracture, open Multiple fractures involving skull or face with other bones, closed Multiple fractures involving skull or face with other bones, open Concussion with loss of consciousness of 30 minutes or less Concussion with loss of consciousness from 31 to 59 minutes Concussion with moderate loss of consciousness Concussion with prolonged loss of consciousness and return to pre-existing conscious level Concussion with prolonged loss of consciousness, without return to pre-existing consciousness level Concussion with loss of consciousness of unspecified duration Cerebral laceration and contusion Subarachnoid, subdural, and extradural hemorrhage, following injury Other and unspecified intracranial hemorrhage following injury Intracranial injury of other and unspecified nature Late effects of fracture of skull and face bones Late effects of intracranial injury without mention of skull fracture Iatrogenic cerebrovascular infarction or hemorrhage V15.52 Personal history of traumatic brain injury Appendix B ( Note: This list of codes may not be all-inclusive) Experimental/Investigational/Unproven/Not Covered: ICD-9-CM Diagnosis Codes Dementias Dementia in conditions classified elsewhere without behavioral disturbance Dementia in conditions classified elsewhere 3

4 Experimental/Investigational/Unproven/Not Covered: ICD-9-CM Diagnosis Codes with behavioral disturbance Other persistent mental disorders due to conditions classified elsewhere Unspecified persistent mental disorders due to conditions classified elsewhere Schizophrenic disorders Pervasive developmental disorders Tourette s disorder Personality change due to conditions classified elsewhere Attention deficit disorder without mention of hyperactivity Attention deficit disorder with hyperactivity Hyperkinesis with developmental delay Specific delays in development Alzheimer s disease Frontotemproal dementia Dementia with Lewy bodies 340 Multiple sclerosis Infantile cerebral palsy Toxic encephalopathy 436 Acute, but ill-defined CV disease Non-ruptured cerebral aneurysm Late effects of cerebrovascular disease; speech and language deficits Other late effects of cerebrovascular disease Down s syndrome Abnormality of gait Lack of coordination Lack of normal physiological development, unspecified Delayed milestones Other speech disturbance Concussion with no loss of consciousness Concussion, unspecified V11.0 Personal history of schizophrenia V57.22 Encounter for vocational therapy All other codes 4

5 CMP Number: CMP Cross Reference: CMP-053 References: Anthem Medical Policy,, 10/12/11. Brain Injury Resource Center,. Source: NIH Pub.No Cicerone, KD et al, Evidence-based : Updated review of the literature from 2003through 2008, Arch Phys Med Rehabil, 2011, Apr; 92(4): Cicerone, KD et al, A Randomized Controlled Trial of Holistic Neuropsychiatric Rehabilitation after Traumatic Brain Injury, Arch Phys Med Rehabil 2008, Dec; 89(12): CIGNA Medical Coverage Policy,, 5/15/2014., United Healthcare, Medical Policy # 2011T01441, May 1, 2014 Consensus Conference. Rehabilitation of persons with traumatic brain injury, NIH Consensus Development panel on Rehabilitation of Persons with Traumatic Brain Injury, JAMA 1999 Sep 8; 282(10): and JAMA 2000 May 10; 283(18): Local Coverage Determination for Outpatient Physical and Occupational Therapy Services (L29833); CPT 97532: Turner-Stokes, L et al, Multi-disciplinary rehabilitation for acquired brain injury in adults of working age, Cochrane database Syst Rev, 2005 Jul 20(3): CD Wellmark Blue Cross and Blue Shield Medical Policy October 2014 Created: 11/30/11 Annual Review Month: November Review Dates: 10/23/13, 1/21/2014, 1/6/2015 Revision Dates: 1/6/2015 CMC Review Date: 12/05/11, 11/13/12, 1/21/2014, 1/6/2015 CMO Approval Dates: 11/13/12, 1/28/2014, 1/6/2015 Effective Dates: 1/28/2014, 1/6/2015 Disclaimer: This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's coverage plan; a member s coverage plan will supersede the provisions of this medical policy. For information on member-specific benefits, call member services. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. Neighborhood reserves the right to review and revise this policy for any reason and at any time, with or without notice. 5

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