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:

• BEH.00004 Treatment of Autism, Asperger's Syndrome, Rett Syndrome, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder Not Otherwise Specified (NOS)
• CG-REHAB-09 Acute Inpatient Rehabilitation

Medically Necessary:

Cognitive rehabilitation is considered medically necessary in patients 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 patients with traumatic brain injury.  For example, Powell and colleagues (2002) reported on the results of a randomized controlled trial of 112 patients 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 patients 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.

Traumatic brain injury (TBI) is generally defined as brain injury as a result of externally inflicted trauma. Each year, in the U.S., an estimated 70,000–90,000 individuals incur TBI severe enough to cause long-term substantial impairment (National Institutes of Health [NIH] 1999). 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, leisure activity). Accordingly, TBI may have a profound effect on everyday functioning and independent living. (BCBSA, 2008)

Cognitive rehabilitation targets such functions as attention, memory and learning, affect and expression, problem-solving, and executive function. (Hayes, 2008) Cognitive rehabilitation has been proposed as a treatment approach for patients with cognitive defects, including, but not limited to those patients who have suffered TBI.

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 rehabilitation will be required.  It is generally expected that a treatment plan will include but is not limited to documentation that the patient 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 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 

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

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, for the following diagnoses and all other diagnoses not listed, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

Peer Reviewed Publications: 

1. Bowen A, Lincoln NB. Cognitive rehabilitation for spatial neglect following stroke. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD003586. DOI: 10.1002/14651858.CD003586.pub2.
2. Bowen A, Lincoln NB, Dewey M. Cognitive rehabilitation for spatial neglect following stroke (Cochrane Review).  In: The Cochrane Library, Issue 1, 2002.
3. Cicerone K.D, Dahlberg C, Kalmar L, et al.  Evidence-based cognitive rehabilitation: recommendations for clinical practice. Arch Phys Med Rehabil, 2000:81; 1596-1615.
4. 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.
5. Cuesta GM. Cognitive rehabilitation of memory following stroke. Theory, practice, and outcome. Adv Neurol. 2003;92:415-421.
6. 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.
7. Limond J, Leeke R. Practitioner review: cognitive rehabilitation for children with acquired brain injury. J Child Psychol Psychiatry. 2005;46(4):339-352.
8. Lincoln NB, Majid MJ, Weyman N. Cognitive rehabilitation for attention deficits following stroke. Cochrane Database of Systematic Reviews 2000, Issue 4. Art. No.: CD002842. DOI: 10.1002/14651858.CD002842..
9. Majid MJ, Lincoln NB, Weyman N.  Cognitive rehabilitation for memory deficits following stroke. (Cochrane Review) In: The Cochrane Library, Issue 1, 2002.
10. Nair RD, Lincoln NB, Cognitive rehabilitation for memory deficits following stroke. Cochrane Database of Systematic Reviews 2007. Issue 3. Art. No.: CD002293. DOI: 10.1002/14651858.CDC002293.pub2.
11. Powell J, Heslin J, Greenwood R. Community based rehabilitation after severe traumatic brain injury: A randomized controlled trial. J Neurol Neurosurg Psychiatr 2002; 72:193-202.
12. Salazar AM, Warden DL, Schwab K, et al. Cognitive rehabilitation for traumatic brain injury: A randomized trial.  JAMA 2000; 283:3075-3081.
13. Schutz LE, Trainor K. Evaluation of cognitive rehabilitation as a treatment paradigm. Brain Inj. 2007; 21(6):545-557.
14. 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.
15. Turner-Stokes L, Disler PB, Nair A, Wade DT. Multi-disciplinary rehabilitation for acquired brain injury in adults of working age. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD004170. DOI: 10.1002/14651858.CD004170.pub2.

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 Medicare and Medicaid Services. National Coverage Determination for Institutional and Home Care Patient Education Programs. NCD#170.1. Effective date not posted. Available at: http://www.cms.hhs.gov. Accessed on July 6, 2009.
3. Chesnut RM, Carney N, Maynard H, et al. Rehabilitation for traumatic brain injury. Rockville, MD: Agency for Health Care Policy and Research. February 1999.  Available at: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1.section.1287  Accessed on July 6, 2009.
4. 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.
5. Hayes Medical Technology Directory.  Cognitive Rehabilitation for Traumatic Brain Injury. Lansdale, PA. Hayes, Inc. April 2008.
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/elements/media/biaa_cog_rehab_position_statement_2007.pdf  Accessed on July 6, 2009.
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 July 6, 2009.
8. National Institutes of Health (NIH).  Consensus on Rehabilitation of Persons with Traumatic Brain Injury March 1999. Available at:  http://www.nichd.nih.gov/publications/pubs/TBI_1999/NIH_Consensus_Statement.cfm Accessed on July 6, 2009.

Cognitive
Rehabilitation
Traumatic Brain Injury