Cognitive Rehabilitation

POLICY NUMBER

A.8.03.10

DESCRIPTION

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 re-establish 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.

Policy Focus and Scope

Populations

This policy evaluates the efficacy of cognitive rehabilitation (CR) interventions in mitigating cognitive dysfunction among individuals with deficits resulting from traumatic brain injury, stroke, multiple sclerosis, post-acute sequelae of SARS-CoV-2 infection, mild cognitive impairment, or Alzheimer's disease, while specifically excluding other dementia etiologies. The analysis considers the effects of cognitive rehabilitation on cognitive impairments secondary to epilepsy, without addressing other seizure-related disorders.

The policy also considers the use of cognitive rehabilitation for cognitive impairments arising from childhood cancers and adult cancers, including brain tumors and non-central nervous system (CNS) tumors. Cancer therapies can induce cognitive changes commonly known as "chemo-brain", manifesting as challenges with memory, focus, and higher-order cognitive skills. These issues may stem from chemotherapy, radiation, or surgical procedures.

The policy does not consider the use of cognitive rehabilitation for individuals with cognitive deficits due to autism spectrum disorder (ASD) and postencephalopathy:

• Autism Spectrum Disorder encompasses a broad range of conditions affecting social interaction, communication, and behavior. The term "spectrum" highlights the extensive variability of challenges among individuals. ASD includes numerous conditions that impact social interaction, communication, and symptoms, necessitating diverse treatment approaches. These approaches include behavioral and educational interventions, psychopharmacologic interventions, and complementary and alternative therapies.

• Post-encephalitic experiences involve alterations in mental faculties to varying extents, potentially impeding everyday activities. The cognitive impairment patterns following encephalitis vary among individuals, depending on the affected brain systems and the nature of the encephalitis.

Interventions

This policy examines the evidence for cognitive rehabilitation delivered by qualified professionals within clinician-guided programs. It specifically excludes studies initiated during acute inpatient hospital stays. The policy does not evaluate research that is solely based on computerized cognitive training, such as interactive or gamified activities accessed on computers or mobile devices, or the use of virtual reality tools by individuals and their families. Recent research increasingly highlights the effectiveness of computerized cognitive training across diverse populations and cognitive domains.

Outcomes

Short-term improvements in cognitive test performance measured post-intervention alone are insufficient to confirm the utility of cognitive rehabilitation for this policy. Measurements of daily functioning and quality of life are the primary health outcomes of interest. Improvements should be demonstrable after longer-term follow-up post-intervention, preferably greater than 6 months.

Cognitive Rehabilitation

Cognition-oriented treatments (COTs) is a broad term to describe nonpharmacological interventions designed to engage and enhance cognitive functions. Unlike nonpharmacological interventions, which focus on behavioral, emotional, or physical outcomes, COTs aim to improve cognitive processes and their impact on daily functional abilities. COTs for preventing decline in cognition and functional status in older adults include cognitive training, cognitive behavioral therapy, cognitive stimulation therapy, and cognitive rehabilitation. Each approach is distinct based on theoretical assumptions, key elements, and target populations, though overlaps exist, making differentiation challenging. Despite available definitions, these terms are often used interchangeably in the literature.

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 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 re-entry into familial, social, educational, and working environments, the reduction of dependence on assistive devices or services, and general enrichment of quality of life. 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.

Cognitive rehabilitation focuses on identifying and addressing individual needs and goals, which may require strategies for taking in new information or compensatory methods such as using memory aids. Cognitive rehabilitation is a therapeutic approach that encompasses several key elements:

• It emphasizes functionality in daily activities.

• It focuses on specific activities selected by each participant as important, usually framed as personal goals they aspire to achieve.

• An individualized therapy plan is crafted, aimed at enhancing performance or managing these activities, based on an assessment of the participant’s current capabilities and intrinsic capacity, along with an evaluation of the demands of the chosen activities.

• Recognized rehabilitative strategies and methods are employed to help the participant compensate for, manage, or overcome functional limitations concerning the targeted activities.

Cognitive rehabilitation is often categorized into six main domains: complex attention, executive function, learning and memory, language, perceptual-motor control, and social cognition. PMID: 30926291 PMID: 37701470 These areas are commonly evaluated and targeted in rehabilitation programs. The duration and intensity of these programs are customized based on an individual's assessment in these domains. This personalized approach helps create effective treatment plans that address specific cognitive impairments and prioritize functional outcomes.

Cognitive rehabilitation is not subject to regulation by the U.S. Food and Drug Administration.

Cognitive rehabilitation must be distinguished from occupational therapy (CPT codes 97535-97537); occupational therapy describes rehabilitation that is directed at specific environments (i.e., home or work). In contrast, cognitive rehabilitation consists of tasks designed to develop memory, language, and reasoning skills that can then be applied to specific environments, as described by the occupational therapy codes.

Sensory integration and auditory integration therapy may be considered a component of cognitive rehabilitation and are addressed in the Sensory Integration Therapy and Auditory Integration Therapy medical policy.

POLICY

Cognitive rehabilitation (as a distinct and definable component of the rehabilitation process) may be considered medically necessary in the rehabilitation of individuals with cognitive impairment and related functional impairment due to moderate to severe traumatic brain injury when ALL following criteria are met (see Policy Guidelines).

• Cognitive rehabilitation is provided by a qualified licensed professional within clinician-guided program.

• Cognitive rehabilitation is prescribed by the attending physician as part of the written care plan.

• The individual is expected to make significant cognitive and functional improvements based on the preinjury function.

• The individual has sufficient cognitive function to understand and willingly participate in the program and has adequate language expression and comprehension (i.e., the individual is not comatose or in a vegetative state and does not have severe aphasia).

• Ongoing services are considered necessary only when there is demonstrated continued objective improvement in cognitive functioning toward the quantifiable short- and long-term goals.

Cognitive rehabilitation (as a distinct and definable component of the rehabilitation process) is considered investigational for all other applications, including, but not limited to individuals with mild traumatic brain injury, mild cognitive impairment, Alzheimer’s disease, stroke, multiple sclerosis, post-acute sequelae of SARS-CoV-2 infection, epilepsy, and those experiencing cognitive deficits as a result of childhood cancers, adult brain tumors, or non-central nervous system tumors, and is not eligible for coverage.

Coverage of Applied Behavioral Analysis (ABA) for the treatment of autism spectrum disorder is addressed in the Treatment of Autism Spectrum Disorder (ASD) medical policy.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

For services to be considered medically necessary, they must be provided by a qualified licensed professional and must be prescribed by the attending physician as part of the written care plan. Additionally, there must be a potential for improvement (based on pre-injury function), and patients must be able to participate actively in the program. Active participation requires sufficient cognitive function to understand and participate in the program, as well as adequate language expression and comprehension (ie, participants should not have severe aphasia). Ongoing services are considered necessary only when there is demonstrated continued objective improvement in function.

Duration and intensity of cognitive rehabilitation therapy programs vary. One approach for comprehensive cognitive rehabilitation is a 16-week outpatient program comprising 5 hours of therapy daily for 4 days each week. In another approach, cognitive group treatment occurs for three 2-hour sessions weekly and three 1-hour individual sessions (total, 9 hours weekly). Cognitive rehabilitation programs for specific deficits, eg, memory training, are less intensive and generally have 1 or 2 sessions (30 or 60 minutes) per week for 4 to 10 weeks (See Policy Description).

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

This policy is not intended to deny multidisciplinary services, such as physical therapy, occupational therapy, or speech therapy after traumatic brain injury and stroke.

POLICY HISTORY

11/1998: Approved by Medical Policy Advisory Committee (MPAC).

8/9/2001: "Policy Guidelines" section revised; "Code Reference" section updated.

2/13/2002: Investigational definition added.

4/18/2002: Type of Service and Place of Service deleted.

10/3/2002: Description section revised to be consistent with BCBSA policy, Lovaas Therapy for Autism and hyperlink to Sensory Integration Therapy added.

11/27/2002: Sources updated.

3/9/2004: CPT code 97770 deleted.

4/19/2004: Policy reviewed, no changes.

9/17/2004: Code Reference section updated, ICD-9 procedure code 93.89 added.

5/1/2008: Policy reviewed, no changes.

08/03/2010: Policy statement revised to state that cognitive rehabilitation may be considered medically necessary in the rehabilitation of patients with traumatic brain injury. All other indications remain investigational. Procedure codes 97532 and 93.89 moved from non-covered to covered. Added ICD-9 codes 854.00 - 854.19 as covered diagnoses. Deleted outdated references from the Sources section.

03/27/2012: Policy reviewed; no changes.

05/08/2013: Policy reviewed; no changes.

05/08/2014: Policy reviewed. Policy statement revised to add autism spectrum disorders and seizure disorders to the investigational policy statement for cognitive rehabilitation. 

03/16/2015: Policy description updated regarding auditory integration therapy.Policy statement updated to state that coverage of Applied Behavioral Analysis (ABA) for the treatment of autism spectrum disorder is addressed in the Treatment of Autism Spectrum Disorder (ASD) medical policy. Added link to the Treatment of Autism Spectrum Disorder (ASD) medical policy.Deleted autism spectrum disorders from the investigational policy statement. Deleted the following policy statement: Lovaas therapy is considered investigational for treatment of autistic children.

08/25/2015: Code Reference section updated for ICD-10.

02/10/2016: Policy description updated to remove information regarding Lovaas therapy. Policy statement updated to clarify that cognitive rehabilitation may be considered medically necessary in the rehabilitation of patients with cognitive impairment due to traumatic brain injury. Policy statement updated to add multiple sclerosis and patients with cognitive deficits due to brain tumor or previous treatment for cancer as investigational. Policy guidelines updated to define active participation, add information regarding the duration and intensity of cognitive rehabilitation therapy programs, and to add medically necessary and investigative definitions.

04/22/2016: Policy description updated. Policy statements unchanged.

05/27/2016: Policy number A.8.03.10 added.

03/28/2017: Policy description updated regarding FDA regulation. Policy statements unchanged.

12/21/2017: Code Reference section updated to add new 2018 CPT codes 97127, 99483 and HCPCS code G0515.

04/09/2018: Policy reviewed; no changes.

04/05/2019: Policy reviewed; no changes. Code Reference section updated to remove deleted CPT code 97532.

12/19/2019: Code Reference section updated to add new CPT codes 97129 and 97130 effective 01/01/2020.

04/16/2020: Policy reviewed; no changes.

05/26/2021: Policy reviewed. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity." Code Reference section updated to remove deleted CPT code 97127 and HCPCS code G0515.

12/15/2021: Code Reference section updated to revise code description for CPT code 99483, effective 01/01/2022.

09/15/2022: Policy reviewed. Investigational statement updated to include patients with post-acute cognitive sequelae of SARS-CoV-2 infection. Code Reference section updated to add new ICD-10 diagnosis codes S06.2XAA, S06.2XAD, S06.2XAS, S06.30AA, S06.30AD, and S06.30AS, effective 10/01/2022.

12/28/2022: Code Reference section updated to revise the description for CPT code 99483, effective 01/01/2023.

04/17/2023: Policy reviewed. Policy statements updated to change "patients" to "individuals" and "post-encephalopathy" to "post-encephalopathic."

04/25/2024: Policy reviewed; no changes.

05/15/2026: Policy description updated regarding policy focus and scope. Medically necessary policy statement revised to state that cognitive rehabilitation (as a distinct and definable component of the rehabilitation process) may be considered medically necessary in the rehabilitation of individuals with cognitive impairment and related functional impairment due to moderate to severe traumatic brain injury when ALL of the listed criteria are met. It previously stated: Cognitive rehabilitation (as a distinct and definable component of the rehabilitation process) may be considered medically necessary in the rehabilitation of individuals with cognitive impairment due to traumatic brain injury. Policy statement revised to add individuals with mild traumatic brain injury, mild cognitive impairment, Alzheimer’s disease, epilepsy, and those experiencing cognitive deficits as a result of childhood cancers, adult brain tumors, or non-central nervous system tumors to the list of investigational conditions. Policy Guidelines updated. Code Reference section updated to remove ICD-9 procedure and ICD-9 diagnosis codes.

SOURCE(S)

Blue Cross Blue Shield Association policy # 8.03.10

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

Covered Codes

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