Cognitive rehabilitation, as a distinct and definable component of the rehabilitation process, may be considered medically necessary for the rehabilitation of traumatic and acquired brain injury including but not limited to brain hemorrhage, cerebral thrombosis, concussion, fractured skull and post-traumatic encephalopathy, anoxic brain damage and infectious disease such as encephalitis.
Cognitive rehabilitation may be considered medically necessary for individuals who are able to interactively participate in the therapy and are expected to make significant cognitive improvement and ALL of the following:
- The services must be ordered by the attending physician and be part of a written plan of care; and
- The service is so complex that it can only be performed by a qualified licensed professional; and
- The individual is capable of actively participating in the program and capable, by mental status, of demonstrating responsiveness to verbal or visual stimuli and able 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; and
- The individual is expected to show measurable functional improvement within a predetermined time frame (depending on the underlying diagnosis or medical condition) from the start of cognitive rehabilitation therapy. Goals and expected time frames can be addressed before the onset of treatment; and
- The attending physician must review the treatment plan periodically to assess the continued need for participation and document objective evidence of the individuals progress; and
- Neuropsychological testing performed by a neuropsychiatrist or behavioral neurologist and neuropsychological results will be used in treatment-planning and redirecting rehabilitation strategies.
Cognitive rehabilitation not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
A maintenance therapy program includes activities that maintain the individual’s present level of function and prevent regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved or when no further functional progress is apparent or expected to occur. Maintenance therapy is not an eligible service.