Latest Review Date: March 2024

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

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.

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.