Cognitive rehabilitation refers to therapy programs which aid persons in the management of specific problems in perception, memory, thinking and problem solving. Skills are practiced and strategies are taught to help improve function and/or compensate for remaining deficits.

For additional information, please see the following:

• MED.00107 Medical and Other Non-Behavioral Health Related Treatments for Pervasive Developmental Disorders
• CG-REHAB-09 Acute Inpatient Rehabilitation

Medically Necessary:

Cognitive rehabilitation is considered medically necessary in individuals with significantly impaired cognitive function after traumatic brain injury (TBI) if all of the following criteria are met:

1. The service must be prescribed by the attending physician as part of a written plan of care; AND
2. The service(s) is so inherently complex that it can be safely and effectively performed only by a qualified licensed professional such as a physician, licensed psychologist, speech therapist or occupational therapist; AND
3. The individual is capable of actively participating in a cognitive rehabilitation program, as evidenced by a mental status demonstrating responsiveness to verbal or visual stimuli and ability to follow commands and process and retain information; AND
4. 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
5. 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
6. The treating physician should review the treatment plan periodically to assess the continued need for participation and documented objective evidence of progress.

NOTES:

• When the injury leading to the need for rehabilitation is one affecting the central nervous system, concomitant cognitive and physical issues may exist. When physical rehabilitation needs no longer exist, the cognitive issues may be addressed either as part of a formal cognitive rehabilitation program, or if there are continuing speech therapy or occupational therapy needs, with the continuation of these services.
• Cognitive rehabilitation may be provided in the inpatient or outpatient setting.  When performed in the inpatient setting, it is subject to the acute inpatient rehabilitation criteria.  For additional information, please refer to CG-REHAB-09 Acute Inpatient Rehabilitation. 

Investigational and Not Medically Necessary:

Cognitive rehabilitation is considered investigational and not medically necessary for other etiologies of impaired cognitive function, including, but not limited to stroke, dementia, Parkinson's disease or anoxic brain injury.

While cognitive rehabilitation has been investigated in a wide variety of indications, the bulk of the literature has focused on traumatic brain injury and stroke.  The evidence in the published medical literature is difficult to assess due to variability in study design, low power to detect difference or variation in treatment.  Variation in treatment is related to the heterogeneous nature of the treated population; specific cognitive rehabilitative interventions are typically targeted to the specific deficit.  Given these limitations, the published data provides the most support for effectiveness of cognitive rehabilitation in individuals with traumatic brain injury.  For example, Powell and colleagues (2002) reported on the results of a randomized controlled trial of 112 participants with severe traumatic brain injury.  This study suggested that a community-based multidisciplinary rehabilitation program delivered within an individualized contractual goal setting framework is effective in improving functional ability and independence.  Significantly greater improvement was realized by individuals receiving the comprehensive program compared to those receiving a single therapist visit consisting of information only.  In another randomized study of military personnel with a history of traumatic brain injury, Salazar and colleagues (2000) reported an improvement in outcomes with cognitive rehabilitation in those who were unconscious for more than one hour at the time of injury.  As noted in the description, components of treatment vary according to the study and according to the individual.  The duration of therapy also varies, with outpatient, community-based controlled studies reporting between 27 and 32 weeks of therapy, with a variable number of sessions per week.  As with other rehabilitative interventions, goal setting with a demonstration of improvement toward the identified goal is an important aspect of determining the medical necessity of ongoing therapy.

According to the Centers for Disease Control and Prevention (CDC), "a traumatic brain injury is caused by a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain."  These injuries are principally the result of motor vehicle accidents, violence, sports injuries, and falls.  Individuals who have suffered a TBI often experience residual impairments affecting motor control, communication skills, social behavior and cognition.  These deficits may result in a variety of alterations in the individual, including but not limited to changes in memory, language, attention and concentration, visual processing, reasoning, and problem-solving, as well as emotional and behavioral control.  Psychosocial changes may include high levels of anxiety, depression and pervasive personal loss (e.g., interpersonal relationships, social supports, employment, and leisure activity).  Accordingly, TBI may have a profound effect on everyday functioning and independent living. (BCBSA, 2008)

The TEC Assessment Program defines cognitive rehabilitation as: 

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 caused by brain injury. The desired outcome of cognitive rehabilitation is an improved quality of life or an improved ability to function in home and community life. (TEC, 2008)

Cognitive rehabilitation (CR) is distinguished from occupational therapy, which describes rehabilitation that is directed at specific environments (i.e., home or work).  In contrast, CR consists of tasks designed to develop the memory, language and reasoning skills that can then be applied to those specific environments.  CR may be performed by a physician, psychologist, or a speech or occupational therapist.  

As with other rehabilitation services (e.g. physical, speech or occupational therapy), CR services may undergo periodic review to assess how the individual is progressing and to determine the expected length of time CR will be required.  It is generally expected that a treatment plan will include, but is not limited to, documentation that the individual is an acceptable candidate for CR, expected outcomes, expected duration of therapy and evidence of progress toward stated goals as demonstrated by objective functional measurements.  In general, the documentation should provide evidence that there is progress towards reasonable, measurable goals, and that CR continues to be appropriate.  Examples of documentation that may result in therapy not being approved or being discontinued, include but are not necessarily limited to the following:

• The documentation does not clearly demonstrate the need for cognitive rehabilitation (i.e., the individual has a cognitive impairment with compromised functional status); OR
• The documentation indicates that the individual's mental and physical condition prior to the injury is such that significant cognitive improvement is NOT expected; OR
• The documentation indicates that the individual cannot actively participate in the rehabilitation program due to medical instability, severely impaired responsiveness to verbal or visual stimuli, or an inability to follow simple commands; OR. 
• The documentation indicates that the individual fails to show measurable functional improvement within a reasonable period of time (depending on underlying diagnosis/medical condition), typically within 2 - 4 weeks of admission to the cognitive rehabilitation program.   

Cognitive rehabilitation has been proposed as a treatment approach for individuals with cognitive defects, including, but not limited to those individuals who have suffered TBI, Parkinson's disease, stroke and multiple sclerosis.

Tarraga and colleagues (2006) carried out a single-blind, randomized study to investigate the effectiveness of an interactive multimedia internet based system (IMIS) which provided cognitive stimulation to individuals with Alzheimer's disease.  Forty-six (46) mildly impaired individuals suspected of having Alzheimer's disease continued receiving cholinesterase inhibitors (ChEIs) during the 24-week study period.  The participants were divided into three groups: (1) those who received three weekly, 20-minute sessions of IMIS in addition to eight hours per day of an integrated psychostimulation program (IPP); (2) those who received only IPP sessions; and (3) those who received only ChEI treatment.  At 12 weeks, the participants treated with both IMIS and IPP had improved outcome scores on the ADAS-Cog and MMSE, which was sustained through 24 weeks.  The individuals treated with IPP alone had better outcome than those treated with ChEIs alone, but the effects were attenuated after 24 weeks. All of the participants demonstrated improved scores in all of the IMIS individual tasks, attaining higher levels of difficulty in all cases.  Although the results suggest that the IMIS program provided an improvement above and beyond that seen with IPP alone, the researchers acknowledged that the efficacy of the IMIS-type program needs to be evaluated in larger, more diverse populations in order to understand factors that may modify the response as well as to establish its long-term (greater than one year) effects.

Barker-Collo and colleagues (2009) evaluated the effectiveness of Attention Process Training (APT) in improving attention and broader outcomes in stroke survivors 6 months after stroke.  In this single-blinded clinical trial, 78 stroke survivors were randomized to receive either APT or standard rehabilitative care.  The participants were evaluated in four aspects of attention: sustained; selective; divided and alternating as well as the auditory and aspects of attention.  The study participants were randomly assigned to receive standard care plus up to 30 hours of APT or standard care alone.  At six months the participants who had APT had an average improvement of 2.49 standard deviations higher than standard care the participants on "full-scale attention scores".  The researchers acknowledged that APT appears to be a viable and effective means of improving attention deficits in stoke victims, but cautioned that further studies with larger samples and longer follow-up periods are needed to identify the characteristic of those individuals most likely to benefit from APT. 

Sammers and colleagues (2006) examined the effect of cognitive training on cognitive performance of 26 individuals with Parkinson's disease (PD).  Half of the subjects participated in a cognitive training regimen, while the other subjects received standard treatment.  The results demonstrated improved performance of the group with cognitive treatment in two executive tasks after the training period, while no improvement was seen in the group receiving standard treatment.  While the results of the study are encouraging and suggest that individuals with PD might benefit from a short-term cognitive executive function training program, larger, randomized controlled trials with a longer follow-up periods are needed before conclusions regarding its effectiveness can be drawn.  It also remains to be seen if the therapy results in improvement in the everyday life of the participants. 

In the study completed by Flavia and colleagues (2010), researchers evaluated the efficacy of a computer-based intensive training program of attention, information processing and executive functions in individuals with clinically-stable relapsing-remitting (RR) multiple sclerosis (MS) and low levels of disability.  Examinations were performed on 150 individuals with RR-MS who scored less than or equal to four (4) on the Expanded Disability Status Scale (EDSS).  Information processing, working memory and attention were assessed using the Paced Auditory Serial Addition Test (PASAT) and executive function evaluated by the Wisconsin Card Sorting Test (WCST).  Individuals with one or more clinical exacerbations in the previous year, loss of visual acuity, ongoing major psychiatric disorder, substance abuse or a Mimi Mental State Examination score of less than 24 were excluded from the study.  Twenty clinically-stable subjects with RR MS were included in the study and were casually assigned by a blinded psychologist to either a study group (n = 10) or a control group (n = 10).  Therapy continued for a period of three months.  The researchers concluded that a computer-based intensive training program focused on attention, information processing and executive functions is effective in individuals RR MS and low levels of disability.  Larger studies with longer periods of follow-up are needed before these results can be generalized and to demonstrate that the effects of the training persist over time.

In the evidence-based review of cognitive rehabilitation for individuals with multiple sclerosis, researchers concluded that cognitive rehabilitation for multiple sclerosis is still in its infancy stage and more methodologically rigorous research is needed to determine the effectiveness of the various cognitive rehabilitation interventions (O'Brien, 2008.)

While cognitive rehabilitation has been demonstrated to be an effective treatment option for individuals who have suffered a TBI, additional research and well designed studies are needed before conclusions can be drawn regarding its benefits in individuals with multiple sclerosis, Parkinson's disease and those who have suffered a stroke.

Cognitive function:  The ability to selectively focus on information, obtain knowledge, and properly apply knowledge; the conscious intellectual activity of knowing, thinking, learning, judging, reasoning and remembering.

Cognitive stimulation:  One of the therapeutic strategies frequently included in a cognitive rehabilitation program.

Rehabilitation:  A structured set of therapeutic activities that are directed at re-entry into familial, social, educational and working environments, the reduction of dependence on assistive devices or services, and the general enrichment of quality of life.

Traumatic brain injury (TBI):  Damage to the brain caused by a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain. Most instances of traumatic brain injury are the result of motor vehicle accidents, violence, sports injuries and falls.

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met: 

When services are Investigational and Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met or for all other diagnoses not listed, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

Future ICD-10 coding (effective 10/01/2013)
A draft of ICD-10 Coding related to this document, as it might look today, is available for reference and comments at: Appendix 1: Future ICD-10 coding

Peer Reviewed Publications:

1. Barker-Collo SL, Feigin VL, Lawes CM, et al. Reducing attention deficits after stroke using attention process training: a randomized controlled trial. Stroke. 2009; 40(10):3293-3298. Available at: http://pt.wkhealth.com/pt/re/aha/pdfhandler.00007670-200910000-00025.pdf;jsessionid=MGQGJTJXhjqqBkJJktvn2tkz9ywJzv4HWy9KVy2LW2Chp84PN5LS!1986820555!181195628!8091!-1  Accessed on June 28, 2011.
2. Bowen A, Lincoln NB. Cognitive rehabilitation for spatial neglect following stroke. Cochrane Database Syst Rev. 2007;(2):CD003586.
3. Bowen A, Lincoln NB, Dewey M. Cognitive rehabilitation for spatial neglect following stroke. Cochrane Database Syst Rev. 2002; (2):CD003586.
4. Cicerone K.D, Dahlberg C, Kalmar L, et al.  Evidence-based cognitive rehabilitation: recommendations for clinical practice. Arch Phys Med Rehabil. 2000; 81(12):1596-1615.
5. Cicerone KD, Dahlberg C, Malec JF, et al. Evidence-based cognitive rehabilitation: updated review of the literature from 1998 through 2002. Arch Phys Med Rehabil. 2005; 86(8):1681-1692.
6. Cuesta GM. Cognitive rehabilitation of memory following stroke. Theory, practice, and outcome. Adv Neurol. 2003; 92:415-421.
7. Flavia M, Stampatori C, Zanotti D, et al. Efficacy and specificity of intensive cognitive rehabilitation of attention and executive functions in multiple sclerosis. J Neurol Sci. 2010; 288(1-2):101-105.
8. Laatsch L, Harrington D, Hotz G, et al. An evidence-based review of cognitive and behavioral rehabilitation treatment studies in children with acquired brain injury. Head Trauma Rehabil. 2007; 22(4):248-256.
9. Limond J, Leeke R. Practitioner review: cognitive rehabilitation for children with acquired brain injury. J Child Psychol Psychiatry. 2005; 46(4):339-352.
10. Lincoln NB, Majid MJ, Weyman N. Cognitive rehabilitation for attention deficits following stroke. Cochrane Database Syst Rev. 2000; (4):CD002842.
11. Majid MJ, Lincoln NB, Weyman N.  Cognitive rehabilitation for memory deficits following stroke. Cochrane Database Syst Rev. 2000; (3):CD002893.
12. Nair RD, Lincoln NB, Cognitive rehabilitation for memory deficits following stroke. Cochrane Database Syst Rev. 2007; (3):CD002293.
13. O'Brien AR, Chiaravalloti N, Goverover Y, Deluca J. Evidenced-based cognitive rehabilitation for persons with multiple sclerosis: a review of the literature. Arch Phys Med Rehabil. 2008; 89(4):761-769.
14. Powell J, Heslin J, Greenwood R. Community based rehabilitation after severe traumatic brain injury: A randomized controlled trial. J Neurol Neurosurg Psychiatry. 2002; 72(2):193-202.
15. Salazar AM, Warden DL, Schwab K, et al. Cognitive rehabilitation for traumatic brain injury: a randomized trial.  JAMA. 2000; 283(23):3075-3081.
16. Sammer G, Reuter I, Hullmann K, et al. Training of executive functions in Parkinson's disease. J Neurol Sci. 2006; 248(1-2):115-119.
17. Schutz LE, Trainor K. Evaluation of cognitive rehabilitation as a treatment paradigm. Brain Inj. 2007; 21(6):545-557.
18. Serino A, Ciaramelli E, Santantonio AD, Malaga S, et al. A pilot study for rehabilitation of central executive deficits after traumatic brain injury.  Brain Inj. 2007; 21(1):11-19.
19. Tárraga L, Boada M, Modinos G, et al. A randomised pilot study to assess the efficacy of an interactive, multimedia tool of cognitive stimulation in Alzheimer's disease. J Neurol Neurosurg Psychiatry. 2006; 77(10):1116-1121.
20. Turner-Stokes L, Disler PB, Nair A, Wade DT. Multi-disciplinary rehabilitation for acquired brain injury in adults of working age. Cochrane Database Syst Rev. 2005; (3):CD004170.

Government Agency, Medical Society, and Other Authoritative Publications: 

1. Blue Cross Blue Shield Association. Cognitive rehabilitation for traumatic brain injury in adults. TEC Assessment, 2008; 23(03).
2. Centers for Disease Control and Prevention (CDC). Injury Prevention & Control: Traumatic Brain Injury. Updated May 5, 2011.  Available at: http://www.cdc.gov/traumaticbraininjury/.  Accessed on June 28, 2011
3. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination: Institutional and Home Care Patient Education Programs. NCD #170.1. Effective date not posted. For additional information visit the CMS website at: http://www.cms.hhs.gov. Accessed June 28, 2011.
4. Chesnut RM, Carney N, Maynard H, et al. Rehabilitation for traumatic brain injury. Rockville, MD: Agency for Health Care Policy and Research. February 1999. 
5. European Federation of Neurological Societies (EFNS). EFNS guidelines on cognitive rehabilitation: report of an EFNS task force. Eur J Neurol. 2003; 10(1):11-23.
6. Katz, DI; Ashley MJ, O'Shanick GJ, Connors, SH. Cognitive rehabilitation: the evidence, funding and case for advocacy in brain injury. McLean, VA: Brain Injury Association of America, 2006.  Available at: http://www.biausa.org/biaa-position-papers.htm. .  Accessed on June 28, 2011.
7. National Academy of Neuropsychology (NAN). Cognitive rehabilitation. NAN Position Papers. May 2002. Available at: http://www.nanonline.org/NAN/Files/PAIC/PDFs/NANPositionCogRehab.pdf.   Accessed on June 28, 2011.

Cognitive
Rehabilitation
Traumatic Brain Injury