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Coverage criteria policies

Cognitive rehabilitation

These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for Cognitive Rehabilitation. Please see the Related Content section for a prior authorization form to be completed by the therapist.

Coverage

Cognitive Rehabilitation is generally covered subject to the indications listed below and per your plan documents.

Note: Treatment of developmental cognitive delays is not addressed in this policy. Please refer to Physical and occupational therapy – outpatient habilitative policy.

Indications that are covered

Cognitive rehabilitation is covered as an individual, outpatient service following an acute, acquired brain injury (ABI) due to trauma, stroke, aneurysm, anoxia, carbon monoxide poisoning, encephalitis, brain tumor, concussion, or other acute brain insult.

Initial visits:

  1. Initial requests submitted with a consultation and written orders/treatment plan from a physiatrist, neurologist, or a nurse practitioner (NP) with a specialty in physiatry or neurology that meet criteria 2.A and 2.B below will be approved.
  2. Initial requests submitted without a prior consultation from a physiatrist, neurologist, or an NP with a specialty in physiatry or neurology: Up to ten (10) visits will be approved when documentation from the medical record supports that all of the following criteria are met:
    1. The member has had an acute brain injury within the past twelve months.
    2. The member has had an evaluation by a qualified occupational or speech therapist. Documentation from the treating therapist must clearly state:
      1. Diagnoses, date of injury, and the compromised functional skills related to the cognitive impairment.
      2. Measureable, functional goals, related to the identified compromised cognitive functional skills.
      3. The number of visits required, and estimated duration of therapy.
      4. That the member is willing and able to actively participate in the treatment plan.
      5. That the member is expected to make significant cognitive improvement and gains in functional skills.

Visits beyond those approved in the initial treatment plan:

  1. Request for visits after the initial ten (10) visits approved prior to a physiatrist, neurologist, or NP with a physiatry or neurology specialty consult: Visits after the initial 10 will be considered when the criteria for initial visits above are met and the member has had a consultation and written orders/ treatment plan from a physiatrist, neurologist, or NP with a physiatry or neurology specialty. The consultation must occur before the eleventh (11th) visit when the assessment indicates the member needs more than 10 visits.
  2. Requests for visits beyond those initially ordered by the physiatrist, neurologist, or NP with a physiatry or neurology specialty: Visits beyond those initially ordered in the treatment plan by the physiatrist, neurologist, or NP will be considered when the criteria for initial visits above are met and the member has had another consultation and written orders from the physiatrist, neurologist, or NP with a physiatry or neurolgy specialty.

Indications that are not covered

  1. Cognitive Rehabilitation is not covered for non-acute neurological conditions, including, but not limited to:
    1. Brain injuries that occurred greater than one year prior to the start of cognitive rehabilitation.
    2. Cerebral palsy, pervasive developmental disorders, including learning disabilities, low IQ, and autism.
    3. Dementia, including, but not limited to that resulting from Alzheimer’s disease, HIV-infection, Korsakoff’s syndrome, or Parkinson’s disease.
    4. Cognitive decline resulting from chronic diseases including, but not limited to multiple sclerosis, congestive heart failure, chronic obstructive pulmonary disease, or post chemotherapy.
    5. Behavioral/psychiatric disorders including, but not limited to attention-deficit/hyperactivity disorder or schizophrenia.
    6. Coma stimulation to treat comatose or minimally responsive individuals.
  2. Cognitive therapy for Improvement of academic or work performance, including return to work.
  3. Driving evaluations.
  4. Therapy beyond 10 visits without consultation and orders from a physiatrist, neurologist or NP with a specialty in physiatry or neurology.
  5. Continued therapy is not covered when:
    1. Identified goals are met; or
    2. No measureable progress toward goals has been made since the most recent evaluation by the therapist.

Definitions

Cognitive rehabilitation - A systematic, functionally oriented service of therapeutic activities that is based on an assessment and understanding of the member’s cognitive deficits. Services are directed to achieve functional changes by reinforcing, strengthening, reestablishing previously learned patterns of behavior and to establish new patterns of cognitive activity or mechanisms to compensate for impaired neurological systems. The goal of cognitive rehab is to maximize functional independence with minimal interference from cognitive limitations.

Acquired Brain Injury (ABI) - An acquired brain injury is an injury to the brain that has occurred after birth, but is not related to congenital defect or degenerative disease. Causes of ABI include (but are not limited to) hypoxia, illness, infection, stroke, substance abuse, toxic exposure, trauma, and tumor. ABI may cause temporary or permanent impairment in such areas as cognitive, emotional, metabolic, motor, perceptual motor and/or sensory brain function.

Concussion - A type of traumatic brain injury, or TBI, caused by a bump, blow, or jolt to the head that can change the way the brain normally works. Concussions can also occur from a fall or a blow to the body that causes the head and brain to move quickly back and forth.

Functional skills - Essential activities of daily life common to all members such as dressing, feeding, ambulation, transfers and fine motor skills. Measurable progress emphasizes mastery of functional skills and independence in the context of the member's potential ability as specified within a care plan or treatment goals.

Pervasive Developmental Disorder - A group of disorders characterized by delays in the development of socialization and communication skills. Examples include, but are not limited to Autism, Asperger's Syndrome, Childhood Disintegrative Disorder, and Rett's Syndrome.

If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all inclusive.

Covered if criteria are met:

    Codes

    Description

    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

    97535

    Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each 15 minutes

Not covered:

    Codes

    Description

    97537

    Community/work reintegration training (eg, shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact by provider, each 15 minutes

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Brasure M., Lamberty G..,, Sayer N., Nelson N., MacDonald R., Ouellette J., …Wilt, T. (2012) . 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.
  2. Cicerone, K.D., Langenbahn, D.M., Braden, C., Malec, J.F., Kalmar, K., Fraas, M., … Ashman, T. (2011). Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature from 2003 through 2008. Arch Phs Med Rehabil, 92: 519-530.
  3. Chung C., Pollock A., Campbell T., Durward B., Hagen S. (2010) Cognitive rehabilitation for executive dysfunction in patients with stroke or other adult non-progressive acquired brain damage. Cochrane Library 2010, Issue 3. ECRI Institute. (2010). Cognitive Rehabilitation for Stroke. Plymouth Meeting, PA: ECRI Institute.
  4. ECRI Institute. (2011). Cognitive Rehabilitation Therapy for Treating Traumatic Brain Injury. Plymouth Meeting, PA: ECRI Institute.
  5. Hayes, Inc. Hayes Medical Technology Directory Report. Cognitive-Behavioral Therapy for the Prevention of Posttraumatic Stress Disorder in Adults. Lansdale, PA: Hayes, Inc.; September, 2013. Reviewed July, 2016.
  6. Hayes, Inc. Hayes Medical Technology Directory Report. Cognitive Rehabilitation for Traumatic Brain Injury (TBI). Lansdale, PA: Hayes, Inc.; June, 2011, Reviewed June 2015.
  7. Hayes, Inc. Hayes Medical Technology Directory Report. Cognitive-Behaviioral Therapy for the Treatment of Attention-Deficit/Hyperactivity Disorder (ADHD). Lansdale, PA: Hayes, Inc.; February, 2011. Reviewed February, 2015/Archived March, 2016.
  8. Hayes, Inc. Hayes Medical Technology Directory Report. Cognitive rehabilitation therapy for Traumatic Brain Injury (TBI). Lansdale, PA: Hayes, Inc.; September, 2017.
  9. Hayes, Inc. Hayes Medical Technology Directory Report. Computerized Neurocognitive Testing (CTN) for Sports-Related Head injury. Lansdale, PA: Hayes, Inc.; January, 2014. Reviewed January, 2016.
  10. IOM (Institute of Medicine). 2011. Cognitive Rehabilitation Therapy for Traumatic Brain Injury: Evaluating the Evidence. Washington, DC: The National Academies Press.
  11. Rohling, M.L., Faust, M.E., Beverly, B., & Demakis, G (2009). Effectiveness of Cognitive Rehabilitation Following Acquired Brain Injury: A Meta- Analytic RE-Examination of Cicerone et al.’s (2000, 2005) Systematic Reviews. American Psychological Association, 23; 20-39.