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Medical Policy: 08.03.01
Original Effective Date: June 2003
Reviewed: November 2011
Revised: January 2005
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Cognitive rehabilitation is a structured set of therapeutic activities designed to retrain an individual’s ability to think, use judgment and make decisions. The focus is on improving deficits in memory, attention, perception, learning, planning, and judgment. The term, cognitive rehabilitation, is applied to a variety of intervention strategies or techniques that attempt to help patients reduce, manage or cope with cognitive deficits. The desired outcome of cognitive rehabilitation is an improved quality of life or an improved ability to function in home and community life. Cognitive rehabilitation may be performed by a physician, psychologist, or a physical, occupational or speech therapist.
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Prior Approval:
Not applicable
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Policy:
Cognitive rehabilitation may be considered medically necessary following a stroke or traumatic brain injury when the plan of care documents specific diagnosis-related goals for a patient who has a reasonable expectation of achieving measurable improvements in a reasonable and predictable period of time.
Cognitive rehabilitation is not a covered benefit if it is considered not medically necessary because it has become a maintenance program. A maintenance program consists of activities that preserve the patient's present level of function and prevents regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur.
Cognitive therapy is considered investigational for all other applications.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 97532 may be used to report cognitive rehabilitation.
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Selected References:
- Ylvisaker Y, Hanks R, Johnson-Greene D. Perspectives on rehabilitation of individuals with cognitive impairment after brain injury: Rationale for reconsideration of theoretical paradigms. The Journal of Head Trauma Rehabilitation 2002 June;17(3):191-209.
- Bellus SB, Kost PP, Vergo JG, Dinezza GJ. Improvements in cognitive functioning following intensive behavioral rehabilitation. Brain Injury 1998;12(2):139-145.
- Ball K al. Effects of cognitive training interventions with older adults. JAMA 2002:vol 288, No. 18; 2271-2281.
- Bach D, Bach M et al., Reactivating Occupational Therapy: A Method to Improve Cognitive Performance in Geriatric Patients. Age and ageing 1995;24:222-226.
- Salazar A, Warden D, Schwab K et al., Cognitive Rehabilitation for Traumatic Brain Injury: A Randomized Trial. JAMA June 21,2000; 283(23):3075-81.
- Ehlers A, Clark D; Hackmann A et al., A Radnomized Controlled Trial of Cognitive Therapy, a Self-help Booklet, and Repeated Assessments as Early Interventions for Posttraumatic Stress Disorder. Arch Gen Psychiatry 2003 Oct;60(10):1024-32.
- Loewenstein DA, Acevedo A, Czaja SJ, Duara R. Cognitive Rehabilitation of Mildy Impaired Alzheimer Disease Patients on cholinesterase Inhibitors. Am J Geriatr Psychiatry 2004 Jul-Aug; 12(4):395-402.
- Ball K, Berch D, Helmers K et al., Effects of Cognitive Training Interventions with Older Adults: A Randomized Controlled Trial. JAMA November 13, 2002 288(18): 2271-81.
- Cognitive Rehabilitation. Official Statement of the National Academy of Neuropsychology. Approved by the Board of Directors, May 2002.
- Clare L, Wilson BA, Carter G et al., Awareness in early-stage Alzheimer's disease: relationship to outcome of cognitive rehabilitation. J Clin Exp Neuropsychol. 2004 Apr;26(2):215-26.
- ECRI. Cognitive Rehabilitation for Traumatic Brain Injury. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2010 April 30. (ECRI Hotline Response) Also available: http://www.ecri.org.
- ECRI. Cognitive Rehabilitation for Stroke. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2010 May 11. (ECRI Hotline Response) Also available: http://www.ecri.org.
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Policy History:
Date Reason Action
October 2010 Annual review Policy renewed
November 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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