Medical Policy: 08.03.01
Original Effective Date: June 2003
Reviewed: October 2014
Revised: October 2014
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.
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.
Practice Guidelines and Position Statements
American Congress of Rehabilitation Medicine
2011-Evidence Based Review for Cognitive Rehabilitation:
Objective: To update our clinical recommendations for cognitive rehabilitation of people with traumatic brain injury (TBI) and stroke, based on literature review from 2003 and 2008.
Conclusion: There is substantial evidence to support interventions for attention, memory, social communication skills, executive function and for comprehensive-holistic neuropsychologic rehabilitation after TBI (traumatic brain injury). Evidence supports visuospatial rehabilitation after right hemisphere stroke, and interventions for aphasia and apraxia after left hemisphere stroke. Together with our prior reviews, we have evaluated a total of 370 interventions, including 65 class I or Ia studies. There is now sufficient information to support evidence-based protocols and implement empirically supported treatments for cognitive disability after TBI (traumatic brain injury) and stroke.
Cognitive Rehabilitation Treatment Duration
Duration and intensity of cognitive rehabilitation therapy programs vary:
- One approach for comprehensive cognitive rehabilitation is a 16 week outpatient program consisting of 5 hours of therapy a day, 4 days per week. In this approach cognitive group treatment occurs for three 2-hour sessions each week and three 1-hour session (total of 9 hours per week).
- Cognitive rehabilitation programs for specific deficits, such as memory training or visuo-spatial deficits which may be considered less intensive, generally have 1 or 2 sessions (30 to 60 minutes) per week for 4 to 10 weeks.
Sensory integration therapy may be considered a component of cognitive rehabilitation, sensory integration is considered separately. See medical policy 08.03.04
Cognitive rehabilitation may be considered medically necessary following a stroke or traumatic brain injury in addition to these conditions, all of the following criteria must be met:
- The service must be ordered by the attending physician and be part of a written plan of care; and
- The service(s) is so complex that it can be safely and effectively performed only by a qualified licensed professional such as a physician, a psychologist, physical therapist, occupational therapist and/or speech therapist; and
- The individual is capable of actively participating in a cognitive rehabilitation program, as evidenced by mental status demonstrating responsiveness to verbal and visual stimuli and ability to follow commands and process and retain information; and
- The individual’s mental and physical condition prior to the injury indicates there is significant potential for improvement (e.g. a complete recovery of pre-injury memory, language or reasoning skills is not required, but there must be a reasonable expectation of improvement that is of practical value to the individual, measured against the individual’s condition at the start of the rehabilitation program), and the individual must have no lasting or major treatment impediment that prevents progress such as severe dementia or aphasia; and
- The individual is expected to show measurable functional improvement within a predetermined timeframe (depending on the underlying diagnosis/medical condition) from the start of cognitive rehabilitation therapy. Goals and expected timeframes should be addressed prior to the onset of treatment; and
- The treating physician should review the treatment plan periodically 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 thean outpatient rehabilitation/therapy program for patients who have suffered a stroke or traumatic brain injury, these services will be counted toward any applicable therapy visit limits in the member’s subscriber contract.
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 rehabilitation is considered not medically necessary when it becomes a maintenance program.
Cognitive rehabilitation is considered investigational for all other indications including but not limited to the following:
- Dementia (Alzheimer’s disease)
- Parkinson’s disease
- Huntington disease
- Cognitive decline in multiple sclerosis and chronic obstructive pulmonary disease
- Systemic lupus erythematosus
- Mental retardation
- Cerebral palsy
- Behavioral/psychiatric disorders to include but are not limited to:
- Attention deficit/hyperactivity disorder
- Social phobia
- Substance abuse disorders
- Pervasive developmental disorders including autism
- Learning disabilities
- Developmental delay
Based on the peer reviewed literature there is insufficient evidence to support the use of cognitive rehabilitation in all other conditions except those indicated above, medical literature is limited and available studies include small study samples and lack of comparison groups and long term follow up. Therefore, cognitive rehabilitation is considered investigational for all other indications except those indicated above.
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
- 97532 may be used to report cognitive rehabilitation.
- 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)
- ECRI. Cognitive Rehabilitation for Stroke. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2010 May 11. (ECRI Hotline Response)
- Langenbahn DM, Ashman T, Cantor J, Trott C. An Evidence-Based Review of Cognitive Rehabilitaiton in Medical Conditions Affecting Cognitive Function. Arch Phys Med Rehabil. 2012 Sep 25. [Epub ahead of print]
- Van Heugten C, Gregorio GW, Wade D. Evidence-based cognitive rehabilitation after acquired brain injury: a systematic review of content of treatment. Neuropsychol Rehabil. 2012;22(5):653-73.
- Cognitive Rehabilitation. A position paper of the brain injury association of America. Approved by the Board of Directors, November 2006.
- Keith D. Cicerone et. al. Evidence Based Cognitive Rehabilitation: Updated Review of Literature from 2003 through 2008. Arch Phys Med Rehabil Vol 92, April 2011.
- American Speech Language Hearing Association (ASHA). Position Statement-Roles of Speech-Language Pathologists in the Identification, Diagnosis, and Treatment of Individuals with Cognitive Communication Disorders. www.asha.org
- American Speech Language Hearing Association (ASHA). Technical Report Rehabilitation of Children and Adults with Cognitive-Communication Disorders After Brain Injury. www.asha.org
- The Society for Cognitive Rehabilitation (SCR), Recommendations for Best Practice in Cognitive Rehabilitation Therapy: Acquired Brain Injury (2004) www.cognitive-rehab.org
- Brain Injury Association of American, Cognitive Rehabilitation: The Evidence, Funding and Case for Advocacy in Brain Injury. www.biausa.org
- National Guideline Clearinghouse. Traumatic Brain Injury Medical Treatment Guidelines. Colorado Division of Workers Compensation. Nov 2012 www.guideline.gov
- American Heart Association/American Stroke Association. Cognitive Rehabilitation for Executive Dysfunction in Adults with Stroke or other Adult Nonprogressive Acquired Brain Damage. June 18, 2013. http://stroke.ahajournals.org/content/44/7/e77
- Karin Gehring et. al. Cognitive Rehabilitation in Patients with Gliomas a Randomized, Clinical Trial. Journal of Clinical Oncology 27:3712-3722 2009.
Date Reason Action
October 2010 Annual review Policy renewed
November 2011 Annual review Policy renewed
November 2012 Annual review Policy renewed
October 2013 Annual review Policy renewed
October 2014 Annual review Policy revised
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 © 2012 American Medical Association. All Rights Reserved.