Medical Policy: 08.03.01
Original Effective Date: June 2003
Reviewed: August 2017
Revised: August 2016
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 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 designed to reinforce or reestablish previously learned patterns of behavior or to establish new compensatory mechanisms for impaired neurologic systems. 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.
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
For the aging population, including patients with Alzheimer disease, and for patients with cognitive deficits due to post-encephalopathy, autism spectrum disorder, seizure disorder, multiple sclerosis, brain tumor or previous treatment of cancer, evidence on cognitive rehabilitation is insufficient to permit conclusions. Larger studies with longer follow up are needed to demonstrate durable benefits of cognitive rehabilitation therapy in these patients.
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 made 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 unproved.
- 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.
- 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.
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.
2013 Evidence Based Review of Cognitive Rehabilitation in Medical Conditions Affecting Cognitive Function:
The American Congress of Rehabilitation Medicine has developed clinical recommendations for cognitive rehabilitation interventions for individuals with traumatic brain injury (TBI) or stroke.
Summary and Recommendations
- Brain Neoplasms
- Probably effective in treating attention and memory deficits in children and adolescents who undergo resection, radiation or both after diagnosis of brain neoplasm.
- Evidence of effectiveness of these approaches in adults with brain neoplasms is equivocal, thus preventing a recommendation to be made for adults in this population.
- Epilepsy/Seizure Disorders: practice option that cognitive rehabilitation for attention and memory deficits, with additional techniques for internalization of strategy use, may be effective for individuals with seizure related deficits in attention and memory. It is recommended that further cognitive rehabilitation research involving individuals with seizure disorders consider including strategy use as a specific component of training.
- Anoxia/Hypoxia: There is currently insufficient evidence to recommend or contraindicate the use of cognitive rehabilitation in individuals with cognitive impairment from anoxia or hypoxia. It is recommended that foundation cognitive rehabilitation research with this population being with single-subject or small sample studies with careful subject selection (i.e. individuals screened for relatively milder deficits and indications of learning potential), using targeted interventions, and aimed at measurable functional goals.
- Encephalitis: There is currently insufficient evidence to make recommendations for the use of cognitive rehabilitation with postencephalitis cognitive deficits.
- Toxic Encephalopathy: There is insufficient evidence to date to support putting forward a treatment recommendation in this area.
- Parkinson’s Disease: There is insufficient evidence to make recommendations for cognitive rehabilitation for individuals with Parkinson’s disease.
- Huntington Disease: There is insufficient evidence to date to support putting forward a treatment recommendation in this area.
- Systemic Lupus Erythematosus: There is insufficient evidence to date to support a treatment recommendation in this area. It is recommended that researchers of this population focus in areas of cognitive difficulty also common to other diagnostic groups (e.g. attention and/or memory), select individuals with identifiable, yet treatment deficits, and choose intervention methods based in process training and strategy use.
National Institute of Health and Care Excellence (NICE)
National Institute of Health and Care Excellence guidance (2013) on stroke rehabilitation recommends cognitive rehabilitation for visual neglect and memory and attention deficits that impact function. Interventions should focus on relevant functional tasks, e.g, errorless learning and elaborative techniques (mnemonics, encoding strategies) for memory impairments.
INCOG Guidelines for Cognitive Rehab
The team recommends that individuals have detailed assessments of cognition after resolution of posttraumatic amnesia. Cognitive assessment and rehabilitation should be tailored to the patient's neuropsychological profile, premorbid cognitive characteristics, and goals for life activities and participation. Clinical algorithms and audit tools to evaluate current practice are provided.
American Academy of Neurology
In their “Practice Parameters: Assessment and Management of Patients in the Persistent Vegetative State,” the AAN makes no reference to sensory stimulation as a treatment modality (Updated July 2016).
Classification of Traumatic Brain Injury
Traumatic brain injury is frequently classified using multiple scoring symptoms. These can include time of unconsciousness, changes in brain imaging, and multiple scoring systems. The Glasgow Coma Scale/Glasgow Coma Score (GCS) is frequently utilized to determine severity of brain injury. Persons with a GCS of 13-15 are classified with a mild traumatic brain injury.
Glasgow Coma Score
The GCS is scored between 3 and 15, 3 being the worst, and 15 the best. It is composed of three parameters : Best Eye Response, Best Verbal Response, Best Motor Response, as given below : Persons with a score ≥ 13 would be considered to have a mild traumatic brain injuy.
- Best Eye Response. (4)
- No eye opening.
- Eye opening to pain.
- Eye opening to verbal command.
- Eyes open spontaneously.
- Best Verbal Response. (5)
- No verbal response
- Incomprehensible sounds.
- Inappropriate words.
- Best Motor Response. (6)
- No motor response.
- Extension to pain.
- Flexion to pain.
- Withdrawal from pain.
- Localising pain.
- Obeys Commands.
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 in the rehabilitation of patients with cognitive impairment following a stroke or moderate to severe 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.
Note: 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:
- Alzheimer’s disease
- Parkinson’s disease
- Huntington disease
- Multiple sclerosis
- Chronic obstructive pulmonary disease
- Systemic lupus erythematosus
- Anoxia/hypoxia, anoxic brain injury
- Toxic encephalopathy
- 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
- Autism spectrum disorder
- Epilepsy or seizure disorders
- Previous treatment of cancer
- Patients with cognitive deficits due to brain tumor
- Mild traumatic brain injury, including concussion
- Decline in executive function (e.g. memory, organization, self-awareness…) not related to moderate or severe brain injury or stroke.
Cognitive rehabilitation for coma stimulation, also called coma arousal program/therapy, sensory stimulation, and multi-sensory stimulation programs, for any indication, including coma or persistent vegetative state, because it is considered investigational.
Based on the peer reviewed literature there is insufficient evidence to support the use of cognitive rehabilitation in all other conditions except for traumatic brain injury and stroke as 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 for traumatic brain injury and stroke as 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.
- 97127 Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact
- G0515 Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes
- S9056 Coma stimulation per diem
- 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.
- American Speech Language Hearing Association (ASHA). Technical Report Rehabilitation of Children and Adults with Cognitive-Communication Disorders After Brain Injury.
- The Society for Cognitive Rehabilitation (SCR), Recommendations for Best Practice in Cognitive Rehabilitation Therapy: Acquired Brain Injury (2004)
- Brain Injury Association of American , Cognitive Rehabilitation: The Evidence, Funding and Case for Advocacy in Brain Injury.
- National Guideline Clearinghouse . Traumatic Brain Injury Medical Treatment Guidelines. Colorado Division of Workers Compensation. Nov 2012
- 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.
- Karin Gehring et. al. Cognitive Rehabilitation in Patients with Gliomas a Randomized, Clinical Trial. Journal of Clinical Oncology 27:3712-3722 2009.
- UpToDate . Physical Rehabilitation for Cancer Survivors, Jonas M. Sokolof, M.D., Maryam Rafael Aghalar, M.D., Michael D. Stubblefield, M.D., Topic last updated July 21, 2014.
- Lagenbahn Donna M, Ashman Teresa, Cantor Joshua, Trott Charlotte, An Evidence Based Review of Cognitive Rehabilitation in Medical Conditions Affecting Cognitive Function, American Congress of Rehabilitation Medicine, Physical Medicine and Rehabilitation 2013; 94:271-86
- Togher L, Wiseman-Hakes C, Douglas J, et al. INCOG recommendations for management of cognition following traumatic brain injury, part IV: cognitive communication. J Head Trauma Rehabil. 2014 Jul-Aug;29(4):353-68.
- Bayley MT, et al; INCOG Expert Panel. INCOG guidelines for cognitive rehabilitation following traumatic brain injury: methods and overview. J Head Trauma Rehabil 2014 Jul-Aug;29(4):290-306.
- Centers for Disease Control and Prevention (CDC). Injury Prevention & Control: Traumatic Brain Injury. Updated March 27, 2015.
- Hartwell K, Brady K. Determining appropriate levels of care for treatment of substance use disorders. UpToDate Inc., Waltham, MA. Last reviewed January 2016.
- Bogdanova Y, Yee MK, Ho VT, Cicerone KD. Computerized cognitive rehabilitation of attention and executive function in acquired brain injury: A systematic review. J Head Trauma Rehabil. 2015 Dec 24 [Epub ahead of print].
- Kluwe-Schiavon B, Viola TW, Levandowski ML, et al. A systematic review of cognitive rehabilitation for bipolar disorder. Trends Psychiatry Psychother. 2015;37(4):194-201.
- Lincoln NB, das Nair R, Bradshaw L, et al. Cognitive rehabilitation for attention and memory in people with multiple sclerosis: study protocol for a randomized controlled trial (CRAMMS). Trials. 2015;16(1):556.
- Teasdale G, Jennet B, Assessment of coma and impaired consciousness. A practical scale. Lancet 304(7872):81-84, 1974.
- American Stroke Association (ASA). Clinical Guideline. Adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Published June 2016.
- Brasure M, Lambert GJ, Sayer NA, et al. Multidisciplinary Postacute Rehabilitation for Moderate to Severe Traumatic Brain Injury in Adults. (Prepared by the Minnesota Evidence-based Practice Center under Contract No. 290-2007-10064-I.) AHRQ Publication No. 12-EHC101-EF. Rockville, MD: Agency for Healthcare Research and Quality; June 2012, Updated August 2016.
- National Institute for Health and Care Excellence. Stroke rehabilitation (CG162), June 2013. Reichow B, Servili C, Yasamy MT post Non-specialist psychosocial interventions for children and adolescents with intellectual disability or lower-functioning autism spectrum disorders: a systematic review. PLoS Med 2013; 10(12).
- Isaac C, Januel D. Neural correlates of cognitive improvements following cognitive remediation in schizophrenia: a systematic review of randomized trials. Socioaffect Neurosci Psychol. 2016 Mar 17;6:30054.
- Regan B, Wells Y, Farrow M, et al. MAXCOG-Maximizing Cognition: a randomized controlled trial of the efficacy of goal-oriented cognitive rehabilitation for people with mild cognitive impairment and early Alzheimer disease. Am J Geriatr Psychiatry. Mar 2017;25(3):258-269. PMID 28034509
- Das Nair R, Cogger H, Worthington E, et al. Cognitive rehabilitation for memory deficits after stroke. Cochrane Database Syst Rev. Sep 01 2016;9:CD002293. PMID 27581994
August 2017 - Annual Review, Policy Renewed
August 2016 - Annual Review, Policy Revised
September 2015 - Annual Review, Policy Revised
October 2014 - Annual Review, Policy Revised
October 2013 - Annual Review, Policy Renewed
November 2012 - Annual Review, Policy Renewed
November 2011 - Annual Review, Policy Renewed
October 2010 - Annual Review, Policy Renewed
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