Latest Review Date: March 2025

Category: Therapy                                                    

POLICY:

I.  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; OR
• Brain tumor in children and adolescents.

II. Cognitive rehabilitation (as a distinct and definable component of the rehabilitation process) is considered investigational for all other applications, including, but not limited to the following due to a lack of clinical evidence demonstrating an impact on improved health outcomes:

• Behavioral/psychiatric disorders including but not limited to:
  • Attention deficit/hyperactivity disorder
  • Pervasive developmental disorders including autism spectrum disorder
  • Depression
  • Schizophrenia
  • Substance abuse disorders

• Epilepsy and other seizure disorders
• Movement disorders including but not limited to cerebral palsy and Parkinson’s disease
• Neuromuscular disorders including but not limited to multiple sclerosis
• Postencephalitic or postencephalopathy
• Stroke
• Adult patients with cognitive deficits due to brain tumor or previous treatment for cancer
• Aging population, including patients with Alzheimer disease
• Post-acute cognitive sequelae of SARS-Co-V2

DESCRIPTION OF PROCEDURE OR SERVICE:

Cognitive rehabilitation is a structured set of therapeutic activities with the goal of improving deficits in memory, attention, perception, learning, planning, and judgment. The term cognitive rehabilitation is applied to various intervention strategies or techniques that attempt to help patients reduce, manage, or cope with cognitive deficits caused by brain injury. The desired outcomes are improved quality of life and function in home and community life. The term rehabilitation broadly encompasses reentry into familial, social, educational, and working environments, the reduction of dependence on assistive devices or services, and general enrichment of quality of life.

Cognitive rehabilitation services are provided by a qualified licensed professional as prescribed by the attending physician as part of the written care plan. For example, patients recuperating from traumatic brain injury have traditionally been treated with some combination of physical therapy, occupational therapy, and psychological services as indicated. Cognitive rehabilitation is considered a separate service from other rehabilitative therapies, with its own specific procedures.

Definition:

Traumatic brain injury refers to a disruption of normal brain functioning due to one or more of the following:

• Concussion
• Traumatic cerebral edema
• Diffuse or focal traumatic brain injury including contusion or traumatic intra-axial hemorrhage of the cerebrum, cerebellum or brainstem
• Traumatic extra-axial hemorrhage in the epidural, subdural, or subarachnoid spaces

KEY POINTS

Austin et al (2024) reported results of a systematic review and meta-analysis of cognitive rehabilitation interventions in veterans and service members with traumatic brain injuries. The review included RCTs published by February of 2023 that used adult participants who were US veterans or active-duty service members who had a history of mild-to-moderate TBI that tested cognitive rehabilitation treatments designed to improve cognition and/or everyday functioning and reported objective neuropsychological testing as a primary outcome measure. 8 trials (N = 303 in cognitive rehabilitation; N=261 in control; 97% of whom had a history of mild TBI) were included. 7 of the 8 trials were published after 2013. The mean age of participants was 37 years (SD=7) and between 81% and 100% of participants were male. Limited racial and ethnic information was available from the studies included. The mean length of time since TBI was 6 years (SD=52). Cognitive rehabilitation intervention lengths ranged from 4 to 15 weeks (mean=9.5; SD=). Study quality and risk of bias were evaluated using the Cochrane tool. Overall, the studies were rated as having low risk of bias. Given the variation in outcome measures used across studies, effect sizes were transformed into Cohen's d for meta-analysis. Participants in cognitive rehabilitation showed a significant improvement in overall objective neuropsychological functioning compared to controls (d = 0.22; 95% CI, 0.01 to 0.43; p=.04) but not on performance-based measures of functional capacity (d = 0.16; 95% CI, −0.48 to 0.81; p=.62). Participants in cognitive rehabilitation also had comparatively larger improvements in memory (d= 0.42; 95% CI, 0.13 to 0.70; p=.01) and executive functioning (d = 0.26; 95% CI, 0.01 to 0.51; p=.04) but not on attention (d=0.12; 95% CI, −0.12 to 0.35; p=.33). 4 of the RCTs included postintervention follow-up visits to measure durability of treatment effects. In these 4 studies, treatment effects on overall neuropsychological test performance at 10- or 12-week follow-up were also statistically significant favoring cognitive rehabilitation (d = 0.45; 95% CI, 0.01 to 0.90; p=.04).

A 2013 Cochrane review assessed cognitive rehabilitation for executive dysfunction (planning, initiation, organization, inhibition, problem-solving, self-monitoring, error correction) in adults with nonprogressive acquired brain damage. Sixteen RCTs (N=660 patients; 395 TBI, 234 stroke, 31 other acquired brain injury) were included in pooled analyses. No statistically significant effects on measures of global executive function or individual component functions were found.

Chiaravalloti et al (2016) conducted an RCT evaluating the Story Memory Technique to improve learning and memory in subjects with moderate-severe TBI. Sixty-nine subjects were randomized to treatment or control. Assessments were performed at the end of treatment (5 weeks) and 6 months posttreatment. Statistically significant outcomes favored the treatment group for several measures assessing memory at 5 weeks, while results at 6 months were less definitive.

das Nair et al (2019) conducted the large (N=328), multicenter, assessor-blinded, RCT, which evaluated a group memory rehabilitation program for people with TBI (ReMemBrIn) in 9 sites in England. The group memory rehabilitation intervention involved 10 weekly sessions, each lasting about 1.5 hours, which were delivered by a trained Assistant Psychologist to groups of between 4 to 6 participants. The intervention focused on retraining memory functions and strategies to improve encoding and retrieval. The control group received usual care, which typically included employment rehabilitation services, self-help groups, or specialist charity support. Between 2013 and 2015, 328 individuals were randomized to therapy (N=171) or usual care (N=157). The participants were characterized by a mean age of 45.1 years, median GCS closest to admission of 11.5 (25th, 75th centile=6, 14), a length of initial hospital stay for TBI of 84.2 days, and time since TBI of 100.9 months. On the primary outcome of frequency of memory failures in daily life assessed using the Everyday Memory Questionnaire-patient version at 6 months’ follow-up, the between-group difference was not clinically important (adjusted difference in mean scores –2.1; 95% confidence interval [CI] –6.7 to 2.5; p=.37). For secondary outcomes, there was a significant improvement in goal attainment both at 6 and 12 months, but no differences on others such as mood or quality of life. Important methodological limitations included lack of an active control arm, incomplete assessment of intervention fidelity, and exclusion of over 20% of the sample from the primary analysis.

In 2015, Huntley et al performed a meta-analysis of cognitive interventions in dementia. Thirty-three studies were included. Interventions were divided into categories such as cognitive training, cognitive stimulation, and CR. Studies classified as cognitive stimulation had a significant effect as measured on the Mini-Mental State Examination (MMSE) and the Alzheimer’s Disease Assessment Scale-Cognitive Subscale (ADAS-Cog). Reviewers concluded that benefits measured on the ADAS-Cog were generally not clinically significant.

In a 2013 Cochrane review, Bahar-Fuchs et al evaluated the use of cognitive training (task-focused) or rehabilitation (strategy-focused) in Alzheimer’s disease (AD) and vascular dementia. Evidence from 11 RCTs did not demonstrate improved cognitive function, mood, or activities of daily living in patients with mild-to-moderate AD or vascular dementia with cognitive training. Reviewers cited 1 high-quality RCT of CR in 69 patients with early-stage AD, which showed short-term improvements in patient-rated outcomes.

Amieva et al (2016) reported results of the ETNA3 multicenter RCT comparing 4 therapies: standardized programs of cognitive training (group sessions), reminiscence therapy (group sessions), individualized CR program (individual sessions), and usual care. Six hundred fifty-three patients with mild-to-moderate Alzheimer’s disease were randomized in a 1:1:1:1 ratio at 40 clinical sites. Only the results of the CR program and usual care arms are reported in this rationale.

The primary outcome was the rate of survival without moderately severe to severe dementia at 2 years. Secondary outcomes were cognitive impairment, functional disability, behavioral disturbance, apathy, QOL, depression, caregiver burden, and resource utilization. Participants and clinical staff were not blinded to treatment assigned, but outcome assessments were done by blind physicians and psychologists. The CR therapy consisted of a “made-to-measure” program conducted in individual sessions and adapted to patients’ cognitive abilities. Treatment goals were selected to be personally relevant to the patient. Intention-to-treat analyses were performed using “missing equal failure” to replace missing values. Approximately 90% of participants had the 3-month follow-up visit and 72% had the 24-month visit. There was no difference between the CR group and the usual care group with respect to the primary outcome. However, patients who received CR therapy had less functional decline at 24 months compared to the usual care group, as measured by 1 of the 2 scales assessing functional abilities: the AGGIR scale (p=0.02). The AGGIR is a standardized instrument, used primarily in France, aimed at assessing the dependency of elderly individuals living in institutions as well as in the community. The rate of institutionalization was lower in the CR therapy group (27%) than in the usual care group (19%). These results are promising but, given the lack of consistency in benefits on the 2 functional scales, replication is needed to confirm positive findings.

Regan et al (2017) reported an RCT of a home-based, 4-session, goal-oriented CR program versus usual care in 55 patients with mild cognitive impairment (MCI) and early AD. Patients were community-dwelling with a diagnosis of MCI or AD within 6 months of enrollment and an MMSE score greater than 20. The intervention group received 4 weekly 1-hour therapy sessions delivered by experienced therapists with a focus on addressing personally meaningful goals. All participants identified at least 1 goal for improvement. The usual care group had no contact with the research team between their initial and final assessments. The primary outcome measures were goal performance and satisfaction scores on the Canadian Occupational Performance Measure (COPM). Twelve participants in the intervention group and 3 participants in the control group discontinued study participation and were excluded from the final, per-protocol analysis. For the first identified goal, the intervention group had significantly higher improvements in performance and satisfaction on the COPM than the control group. There were no differences in secondary measures of QOL or anxiety and depression. The per-protocol results were biased due to a high rate of missing data.

Four Cochrane reviews have assessed the effectiveness of cognitive rehabilitation for recovery from stroke. The reviews evaluated spatial neglect, attention deficits, and memory deficits. The most recent updates of these reviews for these 3 domains drew the following conclusions:

•           Spatial neglect: A 2013 update identified 23 RCTs with 628 patients. There was very limited evidence for short-term improvements on tests of neglect with cognitive rehabilitation. However, for reducing disability due to spatial neglect and increasing independence, the effectiveness of cognitive rehabilitation remained unproven.

•           Attention deficit: A 2013 update identified 6 RCTs with 223 patients. There was limited evidence of short-term improvement in divided attention (ability to multitask), but no indication of short-term improvements in other aspects of attention. Evidence for persistent effects of cognitive rehabilitation on attention or functional outcomes was lacking. A 2019 update identified no new trials and concluded that the effectiveness of cognitive rehabilitation for attention deficits following stroke remains unconfirmed.

•           Memory deficit: A 2016 update identified 13 trials with 514 patients. There were statistically significant benefits in subjective measures of memory in the short-term (ie, the first assessment measurement after the intervention) but not in the longer term (ie, the second assessment measurement after the intervention). The quality of the evidence ranged from very low to moderate; there was poor quality of reporting in many studies, lack of consistency in the choice of outcome measures, and small sample sizes.

Gillespie et al (2015) published an overview of Cochrane reviews and a more recent RCT assessing rehabilitation for post-stroke cognitive impairment. Data from 44 trials (N=1,550) were summarized. In addition to post-stroke spatial neglect and attention and memory deficits (addressed in the 4 Cochrane publications previously described), post-stroke perceptual disorders, motor apraxia, and executive dysfunction were reviewed. Conclusions were:

•           Very little high-quality evidence exists for the effectiveness of cognitive rehabilitation for post-stroke cognitive deficits.

•           Current evidence has shown that cognitive rehabilitation for spatial neglect, attention deficits, and motor apraxia improve standardized assessments of impairment immediately after treatment. However, the durability and clinical significance of these improvements are unclear.

•           Evidence for the effectiveness of cognitive rehabilitation for post-stroke memory deficits, perceptual disorders, or executive dysfunction was not identified.

Zucchella et al (2013) conducted an RCT of cognitive rehabilitation in adults after neurosurgery at a single rehabilitation facility in Italy. Time since craniotomy was not reported. Adjuvant chemotherapy or radiotherapy was not administered until after the trial. Of 109 consecutive patients screened for participation, 62 (57%) met minimum cognitive deficit and other criteria and were randomized to usual rehabilitative care with (n=30) or without (n=32) cognitive rehabilitation. Treatment sessions were held 4 times a week for 4 weeks and were comprised of 45 minutes of therapist-guided computer exercises in 6 cognitive domains (time and spatial orientation, visual attention, logical reasoning, memory, executive function) and 15 minutes of cognitive strategizing. At the end of treatment (i.e., at week 4), statistically significant improvements in visual attention and verbal memory were observed in the treatment group compared with controls. Improvements in logical reasoning and executive function were not statistically significant. Limited study follow-up makes the clinical significance of these findings unclear.

Three Cochrane reviews have evaluated cognitive rehabilitation for patients with MS and cognitive impairments. In an update, das Nair et al (2016) included 15 studies with 989 patients. There were no differences in subjective reports of memory functioning or mood. There was some evidence of a significant effect by intervention on objective assessments of memory in both the immediate and long-term follow-up and quality of life in intermediate follow-up. However, this effect on objective memory outcomes and quality of life was no longer statistically significant when studies at high-risk of bias were excluded.

Rosti-Otajarvi and Hamalainen (2014) conducted a Cochrane review of neuropsychological rehabilitation in MS. Twenty RCTs met inclusion criteria ( N=986 patients), including 7 of the 8 trials in the das Nair et al (2016) Cochrane review. Overall quality and comparability of included trials were low due to methodologic limitations and variations in interventions and outcome measures across trials, respectively. In meta-analysis, statistically significant improvements in memory span (based on 2 low-quality trials, n=150 patients; standardized mean difference, 0.54; 95% CI, 0.20 to 0.88; p=.002; I2=0%) and working memory (3 very low-quality trials, n=288 patients; standardized mean difference, 0.33; 95% CI, 0.09 to 0.57; p=.006; I2=0%) were observed with cognitive training compared with controls. Statistically significant improvements in attention, information processing speed, immediate verbal memory, executive functions, and depression were not observed.

Farina et al (2015) in Italy conducted a systematic review of the literature on cognitive rehabilitation for epilepsy. Literature was searched through December 2013, and 18 articles of different types (reviews, methodologic papers, case reports, experimental studies) were identified. Studies were heterogeneous for patient characteristics (type of epilepsy, type of previous treatment [surgery, antiepileptic drugs]), intervention modalities (eg, holistic, focused) and duration, and outcome measures. Reviewers considered the overall quality of evidence to be moderate to low, and results inconsistent (eg, not all studies showed benefit; some showed greater benefit in left-sided seizures, and others showed greater benefit in right-sided seizures).

Helmstaedter et al (2008), in a nonrandomized study, assessed the short-term effects of cognitive rehabilitation on memory deficits in 2 retrospective, matched cohorts of temporal lobe epilepsy surgical patients. Mean age was 36 years. Mean age at onset of epilepsy was 4 years, and mean intelligence quotient (IQ) was 105. Patients who received cognitive rehabilitation (n=55) participated in a 1-month program comprising educational sessions about brain function and cognitive exercises. A cohort of 57 patients received no cognitive rehabilitation. Statistically significant improvements in verbal learning and recognition were observed in right-resected patients who received cognitive rehabilitation. Cognitive rehabilitation had nonsignificant effects in left-resected patients. Study limitations included its retrospective design and baseline imbalances in patients' memory and attention deficits (more severe deficits in the control cohort). The limited evidence base precludes conclusions about cognitive rehabilitation for this indication.

Reichow et al (2013) reported on a systematic review of psychosocial interventions administered by nonspecialists for children and adolescents with intellectual disability (IQ<70) or lower functioning ASD. Five comparative trials in patients with ASD ( N=255 patients) who received cognitive rehabilitation, training, and support were included. Improvements in school performance and developmental outcomes were inconsistent across trials.

Wang and Reid (2013) conducted a pilot study of a novel virtual reality-cognitive rehabilitation intervention in 4 children (mean age, 7.4 years) with ASD. Children with autism, who are difficult to engage, may respond better to virtual reality approaches than to traditional cognitive rehabilitation. Mean nonverbal IQ ranged from 93 to 139. Each child viewed training programs on laptop computers equipped with tracking webcams. The child's image and movements were projected into virtual environments where he/she was required to manipulate virtual objects. Outcomes were measures of contextual processing, defined as "the ability to determine an object's meaning or relevance in a particular context," and of abstraction and cognitive flexibility, with executive functions considered components of contextual processing. After 4 to 6 weeks, all children demonstrated statistically significant improvements in contextual processing and cognitive flexibility. Abstraction scores at baseline were at or close to maximum.

Eack et al (2013) conducted a feasibility study of a comprehensive cognitive rehabilitation intervention, called Cognitive Enhancement Therapy, in 14 "high functioning" adults (mean age, 25 years) with ASD. Cognitive Enhancement Therapy, which was originally developed for patients with schizophrenia, provides social interaction and cognitive training focused on attention, memory, and problem-solving. Mean fullscale IQ of the patient sample was 118 (range, 92 to 157). Eleven (79%) of 14 patients completed 18 months of treatment. Statistically significant changes from baseline were observed in mean composite measures of neurocognition, cognitive style, social cognition, and social adjustment. All components of neurocognition (eg, processing speed, working memory) improved statistically, except attention/vigilance.

Summary of Evidence

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 comprises tasks to reinforce or reestablish previously learned patterns of behavior or to establish new compensatory mechanisms for impaired neurologic systems. Cognitive rehabilitation may be performed by a physician, psychologist, or a physical, occupational, or speech therapist. Evidence in support of the use of cognitive rehabilitation in traumatic brain injury and brain tumor in children and adolescents includes randomized controlled trials, nonrandomized comparison studies, case series, and systematic reviews. Relevant outcomes are functional outcomes and quality of life. For other indications, the evidence is insufficient to determine that the technology results in an improvement in health outcomes.

Practice Guidelines and Position Statements

American Congress of Rehabilitation Medicine

The American Congress of Rehabilitation Medicine (2103) recommended process-based cognitive rehabilitation strategies (e.g., attention process training, strategy acquisition and internalization, self-monitoring, corrective feedback) to treat attention and memory deficits in children and adolescents with brain cancers who undergo surgical resection and/or radiotherapy.

Department of Veterans Affairs/Department of Defense (DOD)

In 2009, the Veterans Administration/Department of Veterans Affairs published guidelines on the treatment of concussion and mild traumatic brain injury, which were updated in 2016, and most recently in 2021. These guidelines addressed cognitive rehabilitation in the setting of persistent symptoms. The 2021 guidelines stated:

• "We suggest that patients with symptoms attributed to mild traumatic brain injury [mTBI] who present with memory, attention, or executive function problems despite appropriate management of other contributing factors (e.g., sleep, pain, behavioral health, headache, disequilibrium) should be referred for a short trial of clinician-directed cognitive rehabilitation services." [Strength of recommendation: "weak for."]
• "We suggest against the use of self-administered computer training programs for the cognitive rehabilitation of patients with symptoms attributed to mTBI." [Strength of recommendation: "weak against."]

A 2019 Veterans Administration/Department of Defense practice guideline on the management of stroke rehabilitation found "insufficient evidence to recommend for or against the use of any specific cognitive rehabilitation methodology or pharmacotherapy to improve cognitive outcomes" and noted "there has been very little advancement in the evidence regarding the use of specific cognitive rehabilitation strategies or techniques to improve clinical outcomes following stroke.

Institute of Medicine

In 2011, the Institute of Medicine published a report on cognitive rehabilitation for traumatic brain injury that included a comprehensive review of the literature and recommendations. The report concluded that "current evidence provides limited support for the efficacy of CRT [cognitive rehabilitation therapy] interventions. The evidence varies in both the quality and volume of studies and therefore is not yet sufficient to develop definitive guidelines for health professionals on how to apply CRT in practice." The report recommended that standardization of clinical variables, intervention components, and outcome measures was necessary to improve the evidence base for this treatment. The Institute of Medicine also recommended future studies with larger sample sizes and more comprehensive sets of clinical variables and outcome measures.

REFERENCES

1. Austin TA, Hodges CB, Thomas ML, et al. Meta-analysis of Cognitive Rehabilitation Interventions in Veterans and Service Members With Traumatic Brain Injuries. J Head Trauma Rehabil. Jan 25 2024.
2. Bahar-Fuchs A, Clare L, Woods B. Cognitive training and cognitive rehabilitation for mild to moderate Alzheimer's disease and vascular dementia. Cochrane Database Syst Rev. Jun 05 2013; 2013(6): CD003260.
3. Bowen A, Hazelton C, Pollock A, et al. Cognitive rehabilitation for spatial neglect following stroke. Cochrane Database Syst Rev. Jul 01 2013; 2013(7): CD003586.
4. Chiaravalloti ND, Sandry J, Moore NB, et al. An RCT to Treat Learning Impairment in Traumatic Brain Injury: The TBI-MEM Trial. Neurorehabil Neural Repair. Jul 2016; 30(6): 539-550.
5. Chung CS, Pollock A, Campbell T, et al. Cognitive rehabilitation for executive dysfunction in adults with stroke or other adult non-progressive acquired brain damage. Cochrane Database Syst Rev. Apr 30 2013; 2013(4): CD008391.
6. das Nair R, Bradshaw LE, Carpenter H, et al. A group memory rehabilitation programme for people with traumatic brain injuries: the ReMemBrIn RCT. Health Technol Assess. Apr 2019; 23(16): 1-194.
7. das Nair R, Cogger H, Worthington E, et al. Cognitive rehabilitation for memory deficits after stroke. Cochrane Database Syst Rev. Sep 01 2016; 9(9): CD002293.
8. das Nair R, Ferguson H, Stark DL, et al. Memory Rehabilitation for people with multiple sclerosis. Cochrane Database Syst Rev. Mar 14 2012; (3): CD008754.
9. das Nair R, Martin KJ, Lincoln NB. Memory rehabilitation for people with multiple sclerosis. Cochrane Database Syst Rev. Mar 23 2016; 3: CD008754.
10. Department of Veterans Affairs/Department of Defense Management and Rehabilitation of Post-Acute Mild Traumatic Brain Injury Work Group. VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of Post-Acute Mild Traumatic Brain Injury. Version 3.0, 2021. www.healthquality.va.gov/guidelines/Rehab/mtbi/VADoDmTBICPGFinal508.pdf.
11. Department of Veterans Affairs/Department of Defense Management of Stroke Rehabilitation Work Group. VA/DoD Clinical Practice Guideline for the Management of Stroke Rehabilitation. Version 4.0, 2019. www.healthquality.va.gov/guidelines/Rehab/stroke/VADoDStrokeRehabCPGFinal8292019.pdf .
12. Department of Veteran Affairs/Department of Defense. VA/DoD clinical practice guideline for management of concussion/mild traumatic brain injury. Washington (DC): Department of Veteran Affairs, Department of Defense; 2009.
13. Eack SM, Greenwald DP, Hogarty SS, et al. Cognitive enhancement therapy for adults with autism spectrum disorder: results of an 18-month feasibility study. J Autism Dev Disord. Dec 2013; 43(12): 2866-2877.
14. Farina E, Raglio A, Giovagnoli AR. Cognitive rehabilitation in epilepsy: An evidence-based review. Epilepsy Res. Jan 2015; 109: 210-218.
15. Gillespie DC, Bowen A, Chung CS, et al. Rehabilitation for post-stroke cognitive impairment: an overview of recommendations arising from systematic reviews of current evidence. Clin Rehabil. Feb 2015; 29(2): 120-128.
16. Helmstaedter C, Loer B, Wohlfahrt R, et al. The effects of cognitive rehabilitation on memory outcome after temporal lobe epilepsy surgery. Epilepsy Behav. Apr 2008; 12(3): 402-409.
17. Huntley JD, Gould RL, Liu K, et al. Do cognitive interventions improve general cognition in dementia? A meta-analysis and meta-regression. BMJ Open. 2015;5(4): e005247.
18. Institute of Medicine. Cognitive rehabilitation therapy for traumatic brain injury: evaluating the evidence. Washington, DC: National Academies Press; 2011.
19. Langenbahn DM, Ashman T, Cantor J, et al. An evidence-based review of cognitive rehabilitation in medical conditions affecting cognitive function. Arch Phys Med Rehabil. Feb 2013; 94(2): 271-286.
20. Loetscher T, Lincoln NB. Cognitive rehabilitation for attention deficits following stroke. Cochrane Database Syst Rev. May 31 2013; 2013(5): CD002842.
21. Management of Concussion-mild Traumatic Brain Injury Working Group. VA/DoD clinical practice guideline for the management of concussion-mild traumatic brain injury, Version 2.0. Washington, DC: Department of Veterans Affairs, Department of Defense; 2016.
22. Nair RD, Lincoln NB. Cognitive rehabilitation for memory deficits following stroke. Cochrane Database Syst Rev. Jul 18 2007; (3): CD002293.
23. Reichow B, Servili C, Yasamy MT, et al. Non-specialist psychosocial interventions for children and adolescents with intellectual disability or lower-functioning autism spectrum disorders: a systematic review. PLoS Med. Dec 2013; 10(12): e1001572; discussion e1001572.
24. Rosti-Otajärvi EM, Hämäläinen PI. Neuropsychological rehabilitation for multiple sclerosis. Cochrane Database Syst Rev. Feb 11 2014; (2): CD009131.
25. Wang M, Reid D. Using the virtual reality-cognitive rehabilitation approach to improve contextual processing in children with autism. ScientificWorldJournal. 2013; 2013: 716890.
26. Zucchella C, Capone A, Codella V, et al. Cognitive rehabilitation for early post-surgery inpatients affected by primary brain tumor: a randomized, controlled trial. J Neurooncol. Aug 2013; 114(1): 93-100.

CURRENT CODING:

CPT Codes:

POLICY HISTORY:

Reviewed and posted July 1, 2021.

July 2022: Annual review completed. No change to policy intent. Updated policy statement to include Post-acute cognitive sequelae of SARS-Co-V2  to the diagnoses considered experimental/investigational.

October 2022: Q4 2022 diagnosis coding update: Effective date 10/3/2022. No changes to coding on policy. 

March 2023: Annual review completed. No changes to policy statement or intent.

March 2024: Annual review completed. No changes to policy statement or intent.

March 2025: Annual review completed. Updated Key Points and References. No changes to policy statement or intent.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent 

      therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.