Cognitive Rehabilitation

Transcription

1 Last Review Date: March 10, 2017 Number: MG.MM.ME.58Cv2 Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the patient meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request for prior authorization. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. EmblemHealth Services Company LLC, ( EmblemHealth ) has adopted the herein policy in providing management, administrative and other services to HIP Health Plan of New York, HIP Insurance Company of New York, Group Health Incorporated and GHI HMO Select, related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc. Definitions Cognitive function Cognitive deficits Cognitive rehabilitation therapy Traumatic brain injury (TBI) 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. Impacts to attention, language, memory, reasoning, executive functions, problem solving, and visual processing. Cognitive rehabilitation, which may be provided in the inpatient or outpatient setting, offers retraining in the ability to think, use judgment and make decisions. The focus is on correcting deficits in memory, concentration and attention, perception, learning, planning, sequencing, and judgment. The goals of treatment are to enhance the person's capacity to process and interpret information and to improve functional ability. There are two basic approaches to cognitive rehabilitation: Restorative where intellectual deficits are bolstered by various repetitive exercises Compensatory where adaptive devices and strategies and modification of the environment are used to restore functioning despite ongoing deficits. These two techniques can be used in combination and can be components of a comprehensive multidisciplinary rehabilitation program that involves other forms of remediation and psychosocial therapy. A single strategy program can target either an isolated cognitive function or multiple functions concurrently. Note: Cognitive rehabilitation should not be confused with cognitive behavior therapy. Cognitive behavior therapy (also known as cognitive therapy) is a form of psychotherapy that emphasizes the role of thought patterns in moods and behaviors. 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. Related Medical Guidelines Neuropsychological Testing

2 Page 2 of 20 Guideline EmblemHealth considers cognitive rehabilitation therapy (as an adjunct to multidisciplinary rehabilitation [e.g., physical, occupational or speech therapy]) to be medically necessary for significantly impaired cognitive function secondary to aneurysm, brain tumors, traumatic brain injury (TBI), brain injury due to cerebrovascular accident (CVA [stroke]), brain injury due to systemic toxin or metabolic derangement 1, or HIV-associated neurocognitive impairment when the all of the following criteria are met: 1. Onset of injury/clinical condition within 6 months of service request 2. Member was active and responsive to verbal or visual stimuli prior to service request and has an ability to follow commands and process and retain information 3. Member has been evaluated by a neuropsychiatrist or neuropsychologist 2 4. Member has completed neuropsychological testing (NPT) and results demonstrate applicability to treatment-planning and implementation of rehabilitation strategies 5. Expectation of significant cognitive improvement; i.e.: a. Mental and physical condition prior to injury indicates significant potential for improvement b. Member is able to actively participate in therapy [e.g., not in a vegetative state, receiving custodial, etc.) 6. Symptoms cannot be attributed to: a. direct effects of a substance b. be better explained by active and poorly controlled symptoms of psychiatric illness in the setting of lack of treatment (such as distractibility due to internal stimuli due to untreated psychosis or poor concentration secondary to severe untreated depressive illness). Psychiatric symptoms should be assessed and appropriately clinically managed prior or concurrently with cognitive rehabilitation therapy for the original traumatic brain injury. Note: When the injury 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. Care Plan Documentation Cognitive rehabilitation may be performed by an occupational therapist, physical therapist, speech/language pathologist, neuropsychologist or physician. A written Care Plan, which includes all of the following components, must be submitted to the plan upon request: 1. Diagnosis and date of onset of the condition 2. Reasonable time-frame estimate for when goals are achievable 3. Specification of long and short-term goals that are quantitative and objective 1 Examples of systemic toxin brain injury include resolving hepatic encephalopathy, resolving uremic encephalopathy, etc. 2 While EmblemHealth requires a neuropsychiatrist or neuropsychologist to perform the evaluation for cognitive rehabilitation therapy, the performance of NPT may be completed by any of following types of providers (as commensurate with NYS licensure): Developmental-behavioral/neurodevelopmental specialist, psychiatrist (MD or DO), clinical psychologist (CP), clinical social worker (CSW), psychiatric nurse practitioner (NP), clinical nurse specialist (CNS) and physician assistant (PA).

3 Page 3 of Cognitive therapy evaluation (completed by neuropsychiatrist or neuropsychologist) 5. Frequency and duration of treatment 6. Specific cognitive rehabilitation therapy techniques to be utilized The Care Plan should be ongoing and updated commensurate with the member s change in condition. Re-evaluation should occur regularly (typically on a monthly basis) and document goalprogression. (Substantiating documentation should link cognitive therapy to the goal-achievements specified in the Care Plan) Utilization Rehabilitation for visuo-spatial deficits generally entails 20 1-hour sessions delivered over the course of 4 weeks. For language and communication deficits, patients usually receive 8 hours of weekly therapy, beginning at 4 weeks post-onset and continuing up to 48 weeks post-onset. Courses of cognitive rehabilitation substantially longer than these durations will be case-by-case reviewed. Limitations/Exclusions 1. Cognitive rehabilitation therapy is not considered medically necessary when: a. Performed as a stand-alone program b. Measurable improvement within a reasonable and predictable period of time is not thought to be achievable c. Member is not making progress toward treatment goals, has reached a plateau or is regressing (demonstrated by the lack of measurable progress towards set goals for at least 1 week) and there is no reasonable expectation of progress despite treatment planning changes d. Member fails to comply with the treatment program, or attendance in therapies is insufficient, to the extent that treatment is not beneficial 2. Cognitive rehabilitation therapy is not considered medically necessary for indications other than those listed above due to insufficient evidence of therapeutic value (including, but not limited to: Epilepsy/seizure disorders, Down syndrome, mental retardation, cerebral palsy [CP], dementia [e.g., Alzheimer s disease, Parkinson s disease], cognitive decline in multiple sclerosis [MS] and chronic obstructive pulmonary disease [COPD], Wernicke encephalopathy and behavioral/psychiatric disorders such as attention-deficit/hyperactivity disorder [ADD/ADHD], depression, schizophrenia, social phobia, substance abuse disorders and pervasive developmental disorders [including autism]). 3. Presence of acute and ongoing substance use resulting in fluctuating level of consciousness. 4. The following treatment modalities are not considered medically necessary due to insufficient evidence of therapeutic value: a. Coma stimulation (aka "Responsiveness Program" [cognitive remediation of comatose persons]), coma arousal program/therapy, sensory stimulation and multi-sensory stimulation programs b. Sensory integration therapy (performed to enhance sensory processing and promote adaptive responses to environmental demands) is regarded as investigational, but may be covered for Medicare members only. Per Local Coverage Determination (LCD): Outpatient Physical and Occupational Therapy Services (L33631), services may be medically necessary for acquired sensory problems resulting from head trauma, illness, or acute neurologic events including CVA. They are not appropriate for patients with progressive neurological conditions without potential for functional adaptation. Therapy

4 Page 4 of 20 is not considered a cure for sensory integrative impairments, but is used to facilitate the development of the nervous system s ability to process sensory input differently. Further, according to the LCD, utilization of this service should be infrequent for Medicare patients. 5. The following services, frequently associated with cognitive rehabilitation programs, are not considered medically necessary as they are not considered primarily medical in nature: a. Vocational rehabilitation b. Structured adult education c. Community re-entry programs d. Behavioral training e. Driving training f. Compensatory devices such as memory books, date books, electronic paging systems or computer-assisted training g. Employment counseling h. Work hardening i. Cognitive therapy provided to improve academic performance j. Music, recreation and/or art therapy k. Intelligence testing (IQ testing) l. Community-based, non-medical services such as clubhouses for socialization, day programs and social skill development programs, supported living programs and independent living centers, and supported employment programs Applicable Procedure Codes Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes Applicable Diagnosis Codes B20 Human immunodeficiency virus [HIV] disease C71.1 Malignant neoplasm of frontal lobe C71.2 Malignant neoplasm of temporal lobe C71.3 Malignant neoplasm of parietal lobe C71.4 Malignant neoplasm of parietal lobe C71.5 Malignant neoplasm of cerebral ventricle C71.6 Malignant neoplasm of cerebellum C71.7 Malignant neoplasm of brain stem C71.8 Malignant neoplasm of overlapping sites of brain C71.9 Malignant neoplasm of brain, unspecified C79.31 Secondary malignant neoplasm of brain C79.32 Secondary malignant neoplasm of cerebral meninges D33.0 Benign neoplasm of brain, supratentorial D33.1 Benign neoplasm of brain, infratentorial D33.2 Benign neoplasm of brain, unspecified D33.3 Benign neoplasm of cranial nerves

5 Page 5 of 20 D43.0 Neoplasm of uncertain behavior of brain, supratentorial D43.1 Neoplasm of uncertain behavior of brain, infratentorial D43.2 Neoplasm of uncertain behavior of brain, unspecified D43.3 Neoplasm of uncertain behavior of cranial nerves F07.81 Postconcussional syndrome G45.0 Vertebro-basilar artery syndrome G45.1 Carotid artery syndrome (hemispheric) G45.2 Multiple and bilateral precerebral artery syndromes G45.3 Amaurosis fugax G45.4 Transient global amnesia G45.8 Other transient cerebral ischemic attacks and related syndromes G45.9 Transient cerebral ischemic attack, unspecified G46.0 Middle cerebral artery syndrome G46.1 Anterior cerebral artery syndrome G46.2 Posterior cerebral artery syndrome G46.3 Brain stem stroke syndrome G46.4 Cerebellar stroke syndrome G46.5 Pure motor lacunar syndrome G46.6 Pure sensory lacunar syndrome G46.7 Other lacunar syndromes G46.8 Other vascular syndromes of brain in cerebrovascular diseases G92 Toxic encephalopathy G93.0 Cerebral cysts G93.1 Anoxic brain damage, not elsewhere classified G93.2 Benign intracranial hypertension G93.40 Encephalopathy, unspecified G93.41 Metabolic encephalopathy G93.49 Other encephalopathy G93.5 Compression of brain G93.6 Cerebral edema G93.7 Reye's syndrome G93.81 Temporal sclerosis G93.89 Other specified disorders of brain G93.9 Disorder of brain, unspecified G94 Other disorders of brain in diseases classified elsewhere G97.31 Intraoperative hemorrhage and hematoma of a nervous system organ or structure complicating a nervous system procedure G97.32 Intraoperative hemorrhage and hematoma of a nervous system organ or structure complicating other procedure I60.00 Nontraumatic subarachnoid hemorrhage from unspecified carotid siphon and bifurcation I60.01 Nontraumatic subarachnoid hemorrhage from right carotid siphon and bifurcation I60.02 Nontraumatic subarachnoid hemorrhage from left carotid siphon and bifurcation I60.10 Nontraumatic subarachnoid hemorrhage from unspecified middle cerebral artery I60.11 Nontraumatic subarachnoid hemorrhage from right middle cerebral artery

6 Page 6 of 20 I60.12 Nontraumatic subarachnoid hemorrhage from left middle cerebral artery I60.2 Nontraumatic subarachnoid hemorrhage from anterior communicating artery I60.30 Nontraumatic subarachnoid hemorrhage from unspecified posterior communicating artery I60.31 Nontraumatic subarachnoid hemorrhage from right posterior communicating artery I60.32 Nontraumatic subarachnoid hemorrhage from left posterior communicating artery I60.4 Nontraumatic subarachnoid hemorrhage from basilar artery I60.50 Nontraumatic subarachnoid hemorrhage from unspecified vertebral artery I60.51 Nontraumatic subarachnoid hemorrhage from right vertebral artery I60.52 Nontraumatic subarachnoid hemorrhage from left vertebral artery I60.6 Nontraumatic subarachnoid hemorrhage from other intracranial arteries I60.7 Nontraumatic subarachnoid hemorrhage from unspecified intracranial artery I60.8 Other nontraumatic subarachnoid hemorrhage I60.9 Nontraumatic subarachnoid hemorrhage, unspecified I61.0 Nontraumatic intracerebral hemorrhage in hemisphere, subcortical I61.1 Nontraumatic intracerebral hemorrhage in hemisphere, cortical I61.2 Nontraumatic intracerebral hemorrhage in hemisphere, unspecified I61.3 Nontraumatic intracerebral hemorrhage in brain stem I61.4 Nontraumatic intracerebral hemorrhage in cerebellum I61.5 Nontraumatic intracerebral hemorrhage, intraventricular I61.6 Nontraumatic intracerebral hemorrhage, multiple localized I61.8 Other nontraumatic intracerebral hemorrhage I61.9 Nontraumatic intracerebral hemorrhage, unspecified I62.00 Nontraumatic subdural hemorrhage, unspecified I62.01 Nontraumatic acute subdural hemorrhage I62.02 Nontraumatic subacute subdural hemorrhage I62.03 Nontraumatic chronic subdural hemorrhage I62.1 Nontraumatic extradural hemorrhage I62.9 Nontraumatic intracranial hemorrhage, unspecified I63.00 Cerebral infarction due to thrombosis of unspecified precerebral artery I Cerebral infarction due to thrombosis of right vertebral artery I Cerebral infarction due to thrombosis of left vertebral artery I Cerebral infarction due to thrombosis of bilateral vertebral arteries I Cerebral infarction due to thrombosis of unspecified vertebral artery I63.02 Cerebral infarction due to thrombosis of basilar artery I Cerebral infarction due to thrombosis of right carotid artery I Cerebral infarction due to thrombosis of left carotid artery I Cerebral infarction due to thrombosis of bilateral carotid arteries I Cerebral infarction due to thrombosis of unspecified carotid artery I63.09 Cerebral infarction due to thrombosis of other precerebral artery I63.10 Cerebral infarction due to embolism of unspecified precerebral artery I Cerebral infarction due to embolism of right vertebral artery I Cerebral infarction due to embolism of left vertebral artery I Cerebral infarction due to embolism of bilateral vertebral arteries

7 Page 7 of 20 I Cerebral infarction due to embolism of unspecified vertebral artery I63.12 Cerebral infarction due to embolism of basilar artery I Cerebral infarction due to embolism of right carotid artery I Cerebral infarction due to embolism of left carotid artery I Cerebral infarction due to embolism of bilateral carotid arteries I Cerebral infarction due to embolism of unspecified carotid artery I63.19 Cerebral infarction due to embolism of other precerebral artery I63.20 Cerebral infarction due to unspecified occlusion or stenosis of unspecified precerebral arteries I Cerebral infarction due to unspecified occlusion or stenosis of right vertebral artery (Revision eff. 10/01/2017) I Cerebral infarction due to unspecified occlusion or stenosis of left vertebral artery (Revision eff. 10/01/2017) I Cerebral infarction due to unspecified occlusion or stenosis of bilateral vertebral arteries I Cerebral infarction due to unspecified occlusion or stenosis of unspecified vertebral arteries I63.22 Cerebral infarction due to unspecified occlusion or stenosis of basilar artery (Revision eff. 10/01/2017) I Cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries I Cerebral infarction due to unspecified occlusion or stenosis of left carotid arteries I Cerebral infarction due to unspecified occlusion or stenosis of bilateral carotid arteries I Cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid arteries I63.29 Cerebral infarction due to unspecified occlusion or stenosis of other precerebral arteries I63.30 Cerebral infarction due to thrombosis of unspecified cerebral artery I Cerebral infarction due to thrombosis of right middle cerebral artery I Cerebral infarction due to thrombosis of left middle cerebral artery I Cerebral infarction due to thrombosis of bilateral middle cerebral arteries I Cerebral infarction due to thrombosis of unspecified middle cerebral artery I Cerebral infarction due to thrombosis of right anterior cerebral artery I Cerebral infarction due to thrombosis of left anterior cerebral artery I Cerebral infarction due to thrombosis of bilateral anterior artery (Revision eff. 10/01/2017) I Cerebral infarction due to thrombosis of unspecified anterior cerebral artery I Cerebral infarction due to thrombosis of right posterior cerebral artery I Cerebral infarction due to thrombosis of left posterior cerebral artery I Cerebral infarction to thrombosis of bilateral posterior artery (Revision eff. 10/01/2017) I Cerebral infarction due to thrombosis of unspecified posterior cerebral artery I Cerebral infarction due to thrombosis of right cerebellar artery I Cerebral infarction due to thrombosis of left cerebellar artery I Cerebral infarction to thrombosis of bilateral cerebellar arteries I Cerebral infarction due to thrombosis of unspecified cerebellar artery I63.39 Cerebral infarction due to thrombosis of other cerebral artery I63.40 Cerebral infarction due to embolism of unspecified cerebral artery I Cerebral infarction due to embolism of right middle cerebral artery I Cerebral infarction due to embolism of left middle cerebral artery I Cerebral infarction due to embolism of bilateral middle cerebral arteries

8 Page 8 of 20 I Cerebral infarction due to embolism of unspecified middle cerebral artery I Cerebral infarction due to embolism of right anterior cerebral artery I Cerebral infarction due to embolism of left anterior cerebral artery I Cerebral infarction due to embolism of bilateral anterior cerebral arteries I Cerebral infarction due to embolism of unspecified anterior cerebral artery I Cerebral infarction due to embolism of right posterior cerebral artery I Cerebral infarction due to embolism of left posterior cerebral artery I Cerebral infarction due to embolism of bilateral posterior cerebral arteries I Cerebral infarction due to embolism of unspecified posterior cerebral artery I Cerebral infarction due to embolism of right cerebellar artery I Cerebral infarction due to embolism of left cerebellar artery I Cerebral infarction due to embolism of bilateral cerebellar arteries I Cerebral infarction due to embolism of unspecified cerebellar artery I63.49 Cerebral infarction due to embolism of other cerebral artery I63.50 Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery I Cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery I Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery I Cerebral infarction due to unspecified occlusion or stenosis of bilateral middle artery (Revision eff. 10/01/2017) I Cerebral infarction due to unspecified occlusion or stenosis of unspecified middle cerebral artery I Cerebral infarction due to unspecified occlusion or stenosis of right anterior cerebral artery I Cerebral infarction due to unspecified occlusion or stenosis of left anterior cerebral artery I Cerebral infarction due to unspecified occlusion or stenosis of bilateral anterior artery (Revision eff. 10/01/2017) I Cerebral infarction due to unspecified occlusion or stenosis of unspecified anterior cerebral artery I Cerebral infarction due to unspecified occlusion or stenosis of right posterior cerebral artery I Cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery I Cerebral infarction due to unspecified occlusion or stenosis of bilateral posterior artery (Revision eff. 10/01/2017) I Cerebral infarction due to unspecified occlusion or stenosis of unspecified posterior cerebral artery I Cerebral infarction due to unspecified occlusion or stenosis of right cerebellar artery I Cerebral infarction due to unspecified occlusion or stenosis of left cerebellar artery I Cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar arteries I Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebellar artery I63.59 Cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery I63.6 Cerebral infarction due to cerebral venous thrombosis, nonpyogenic I63.8 Other cerebral infarction I63.9 Cerebral infarction, unspecified I67.0 Dissection of cerebral arteries, nonruptured I67.1 Cerebral aneurysm, nonruptured I67.2 Cerebral atherosclerosis

9 Page 9 of 20 I67.3 Progressive vascular leukoencephalopathy I67.4 Hypertensive encephalopathy I67.5 Moyamoya disease I67.82 Cerebral ischemia I67.83 Posterior reversible encephalopathy syndrome I Reversible cerebrovascular vasoconstriction syndrome I69.00 Unspecified e of nontraumatic subarachnoid hemorrhage I Attention and concentration deficit following nontraumatic subarachnoid hemorrhage I Memory deficit following nontraumatic subarachnoid hemorrhage I Visuospatial deficit and spatial neglect following nontraumatic subarachnoid hemorrhage I Psychomotor deficit following nontraumatic subarachnoid hemorrhage I Frontal lobe and executive function deficit following nontraumatic subarachnoid hemorrhage I Cognitive social or emotional deficit following nontraumatic subarachnoid hemorrhage I Other symptoms and signs involving cognitive functions following nontraumatic subarachnoid hemorrhage I Unspecified symptoms and signs involving cognitive functions following nontraumatic subarachnoid hemorrhage I Aphasia following nontraumatic subarachnoid hemorrhage I Dysphasia following nontraumatic subarachnoid hemorrhage I Dysarthria following nontraumatic subarachnoid hemorrhage I Fluency disorder following nontraumatic subarachnoid hemorrhage I Other speech and language deficits following nontraumatic subarachnoid hemorrhage I Other e following nontraumatic subarachnoid hemorrhage I69.10 Unspecified e of nontraumatic intracerebral hemorrhage I Memory deficit following nontraumatic intracerebral hemorrhage I Visuospatial deficit and spatial neglect following nontraumatic intracerebral hemorrhage I Psychomotor deficit following nontraumatic intracerebral hemorrhage I Frontal lobe and executive function deficit following nontraumatic intracerebral hemorrhage I Cognitive social or emotional deficit following nontraumatic intracerebral hemorrhage I Other symptoms and signs involving cognitive functions following nontraumatic intracerebral hemorrhage I Unspecified symptoms and signs involving cognitive functions following nontraumatic intracerebral hemorrhage I Aphasia following nontraumatic intracerebral hemorrhage I Dysphasia following nontraumatic intracerebral hemorrhage I Dysarthria following nontraumatic intracerebral hemorrhage I Fluency disorder following nontraumatic intracerebral hemorrhage I Other speech and language deficits following nontraumatic intracerebral hemorrhage I Other e of nontraumatic intracerebral hemorrhage I69.20 Unspecified e of other nontraumatic intracranial hemorrhage I Attention and concentration deficit following other nontraumatic intracranial hemorrhage I Memory deficit following other nontraumatic intracranial hemorrhage I Visuospatial deficit and spatial neglect following other nontraumatic intracranial hemorrhage I Psychomotor deficit following other nontraumatic intracranial hemorrhage I Frontal lobe and executive function deficit following other nontraumatic intracranial hemorrhage I Cognitive social or emotional deficit following other nontraumatic intracranial hemorrhage

10 Page 10 of 20 I Other symptoms and signs involving cognitive functions following other nontraumatic intracranial hemorrhage I Unspecified symptoms and signs involving cognitive functions following other nontraumatic intracranial hemorrhage I Aphasia following other nontraumatic intracranial hemorrhage I Dysphasia following other nontraumatic intracranial hemorrhage I Dysarthria following other nontraumatic intracranial hemorrhage I Fluency disorder following other nontraumatic intracranial hemorrhage I Other speech and language deficits following other nontraumatic intracranial hemorrhage I Other e of other nontraumatic intracranial hemorrhage I69.30 Unspecified e of cerebral infarction I Attention and concentration deficit following cerebral infarction I Memory deficit following cerebral infarction I Visuospatial deficit and spatial neglect following cerebral infarction I Psychomotor deficit following cerebral infarction I Frontal lobe and executive function deficit following cerebral infarction I Cognitive social or emotional deficit following cerebral infarction I Other symptoms and signs involving cognitive functions following cerebral infarction I Unspecified symptoms and signs involving cognitive functions following cerebral infarction I Aphasia following cerebral infarction I Dysphasia following cerebral infarction I Dysarthria following cerebral infarction I Fluency disorder following cerebral infarction I Other speech and language deficits following cerebral infarction I Other e of cerebral infarction I69.80 Unspecified e of other cerebrovascular disease I Attention and concentration deficit following other cerebrovascular disease I Memory deficit following other cerebrovascular disease I Visuospatial deficit and spatial neglect following other cerebrovascular disease I Psychomotor deficit following other cerebrovascular disease I Frontal lobe and executive function deficit following other cerebrovascular disease I Cognitive social or emotional deficit following other cerebrovascular disease I Other symptoms and signs involving cognitive functions following other cerebrovascular disease I Unspecified symptoms and signs involving cognitive functions following other cerebrovascular disease I Aphasia following other cerebrovascular disease I Dysphasia following other cerebrovascular disease I Dysarthria following other cerebrovascular disease I Fluency disorder following other cerebrovascular disease I Other speech and language deficits following other cerebrovascular disease I Other e of other cerebrovascular disease I69.90 Unspecified e of unspecified cerebrovascular disease I Attention and concentration deficit following unspecified cerebrovascular disease I Memory deficit following unspecified cerebrovascular disease I Visuospatial deficit and spatial neglect following unspecified cerebrovascular disease

11 Page 11 of 20 I Psychomotor deficit following unspecified cerebrovascular disease I Frontal lobe and executive function deficit following unspecified cerebrovascular disease I Cognitive social or emotional deficit following unspecified cerebrovascular disease I Other symptoms and signs involving cognitive functions following unspecified cerebrovascular disease I Aphasia following unspecified cerebrovascular disease I Dysphasia following unspecified cerebrovascular disease I Dysarthria following unspecified cerebrovascular disease I Fluency disorder following unspecified cerebrovascular disease I Other speech and language deficits following unspecified cerebrovascular disease I Other e following unspecified cerebrovascular disease I Intraoperative cerebrovascular infarction during cardiac surgery I Intraoperative cerebrovascular infarction during other surgery I Postprocedural cerebrovascular infarction following cardiac surgery I Postprocedural cerebrovascular infarction following other surgery S02.0XXS Fracture of vault of skull, S02.10XS Unspecified fracture of base of skull, S02.110S Type I occipital condyle fracture, S02.111S Type II occipital condyle fracture, S02.112S Type III occipital condyle fracture, S02.113S Unspecified occipital condyle fracture, S02.118S Other fracture of occiput, S02.119S Unspecified fracture of occiput, S06.0X0S Concussion without loss of consciousness, S06.0X1S Concussion with loss of consciousness of 30 minutes or less, S06.0X9S Concussion with loss of consciousness of unspecified duration, S06.1X0S Traumatic cerebral edema without loss of consciousness, S06.1X1S Traumatic cerebral edema with loss of consciousness of 30 minutes or less, S06.1X2S Traumatic cerebral edema with loss of consciousness of 31 minutes to 59 minutes, S06.1X3S Traumatic cerebral edema with loss of consciousness of 1 hour to 5 hours 59 minutes, S06.1X4S S06.1X5S S06.1X6S S06.1X9S S06.2X0S S06.2X1S S06.2X2S Traumatic cerebral edema with loss of consciousness of 6 hours to 24 hours, Traumatic cerebral edema with loss of consciousness greater than 24 hours with return to pre-existing conscious level, Traumatic cerebral edema with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, Traumatic cerebral edema with loss of consciousness of unspecified duration, Diffuse traumatic brain injury without loss of consciousness, Diffuse traumatic brain injury with loss of consciousness of 30 minutes or less, Diffuse traumatic brain injury with loss of consciousness of 31 minutes to 59 minutes, S06.2X3S Diffuse traumatic brain injury with loss of consciousness of 1 hour to 5 hours 59 minutes, S06.2X4S Diffuse traumatic brain injury with loss of consciousness of 6 hours to 24 hours,

12 Page 12 of 20 S06.2X5S S06.2X6S S06.2X9S S06.300S S06.301S Diffuse traumatic brain injury with loss of consciousness greater than 24 hours with return to pre-existing conscious levels, Diffuse traumatic brain injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, Diffuse traumatic brain injury with loss of consciousness of unspecified duration, Unspecified focal traumatic brain injury without loss of consciousness, Unspecified focal traumatic brain injury with loss of consciousness of 30 minutes or less, S06.302S Unspecified focal traumatic brain injury with loss of consciousness of 31 minutes to 59 minutes, S06.303S Unspecified focal traumatic brain injury with loss of consciousness of 1 hour to 5 hours 59 minutes, S06.304S Unspecified focal traumatic brain injury with loss of consciousness of 6 hours to 24 hours, S06.305S S06.306S S06.309S Unspecified focal traumatic brain injury with loss of consciousness greater than 24 hours with return to preexisting conscious level, Unspecified focal traumatic brain injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, Unspecified focal traumatic brain injury with loss of consciousness of unspecified duration, S06.310S S06.311S Contusion and laceration of right cerebrum without loss of consciousness, Contusion and laceration of right cerebrum with loss of consciousness of 30 minutes or less, S06.312S Contusion and laceration of right cerebrum with loss of consciousness of 31 minutes to 59 minutes, S06.313S S06.314S Contusion and laceration of right cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, Contusion and laceration of right cerebrum with loss of consciousness of 6 hours to 24 hours, S06.315S S06.316S S06.319S Contusion and laceration of right cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, Contusion and laceration of right cerebrum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, Contusion and laceration of right cerebrum with loss of consciousness of unspecified duration, S06.320S S06.321S Contusion and laceration of left cerebrum without loss of consciousness, Contusion and laceration of left cerebrum with loss of consciousness of 30 minutes or less, S06.322S Contusion and laceration of left cerebrum with loss of consciousness of 31 minutes to 59 minutes, S06.323S S06.324S Contusion and laceration of left cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, Contusion and laceration of left cerebrum with loss of consciousness of 6 hours to 24 hours,

13 Page 13 of 20 S06.325S S06.326S S06.329S Contusion and laceration of left cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, Contusion and laceration of left cerebrum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, Contusion and laceration of left cerebrum with loss of consciousness of unspecified duration, S06.330S Contusion and laceration of cerebrum, unspecified, without loss of consciousness, S06.331S Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, S06.332S Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, S06.333S Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 1 hour to 5 hours 59 minutes, S06.334S S06.335S S06.336S Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours with return to pre-existing conscious level, Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, S06.339S S06.340S S06.341S Contusion and laceration of cerebrum, unspecified, with loss of consciousness of unspecified duration, Traumatic hemorrhage of right cerebrum without loss of consciousness, Traumatic hemorrhage of right cerebrum with loss of consciousness of 30 minutes or less, S06.342S Traumatic hemorrhage of right cerebrum with loss of consciousness of 31 minutes to 59 minutes, S06.343S S06.344S Traumatic hemorrhage of right cerebrum with loss of consciousness of 1 hours to 5 hours 59 minutes, Traumatic hemorrhage of right cerebrum with loss of consciousness of 6 hours to 24 hours, S06.345S S06.346S S06.349S Traumatic hemorrhage of right cerebrum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, Traumatic hemorrhage of right cerebrum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, Traumatic hemorrhage of right cerebrum with loss of consciousness of unspecified duration, S06.350S S06.351S Traumatic hemorrhage of left cerebrum without loss of consciousness, Traumatic hemorrhage of left cerebrum with loss of consciousness of 30 minutes or less, S06.352S Traumatic hemorrhage of left cerebrum with loss of consciousness of 31 minutes to 59 minutes,

14 Page 14 of 20 S06.353S Traumatic hemorrhage of left cerebrum with loss of consciousness of 1 hours to 5 hours 59 minutes, S06.354S Traumatic hemorrhage of left cerebrum with loss of consciousness of 6 hours to 24 hours, S06.355S S06.356S S06.359S Traumatic hemorrhage of left cerebrum with loss of consciousness greater than 24 hours with return to preexisting conscious level, Traumatic hemorrhage of left cerebrum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, Traumatic hemorrhage of left cerebrum with loss of consciousness of unspecified duration, S06.360S S06.361S Traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness, Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, S06.362S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, S06.363S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 1 hours to 5 hours 59 minutes, S06.364S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, S06.365S S06.366S S06.369S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness greater than 24 hours with return to pre-existing conscious level, Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of unspecified duration, S06.370S Contusion, laceration, and hemorrhage of cerebellum without loss of consciousness, S06.371S Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 30 minutes or less, S06.372S Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 31 minutes to 59 minutes, S06.373S Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 1 hour to 5 hours 59 minutes, S06.374S S06.375S S06.376S Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 6 hours to 24 hours, Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, S06.379S S06.380S Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of unspecified duration, Contusion, laceration, and hemorrhage of brainstem without loss of consciousness,

15 Page 15 of 20 S06.381S S06.382S Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 30 minutes or less, Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 31 minutes to 59 minutes, S06.383S Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 1 hour to 5 hours 59 minutes, S06.384S S06.385S S06.386S Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 6 hours to 24 hours, Contusion, laceration, and hemorrhage of brainstem with loss of consciousness greater than 24 hours with return to pre-existing conscious level, Contusion, laceration, and hemorrhage of brainstem with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, S06.389S S06.4X0S S06.4X1S S06.4X2S S06.4X3S S06.4X4S S06.4X5S S06.4X6S S06.4X9S S06.5X0S S06.5X1S S06.5X2S Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of unspecified duration, Epidural hemorrhage without loss of consciousness, Epidural hemorrhage with loss of consciousness of 30 minutes or less, Epidural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, Epidural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, Epidural hemorrhage with loss of consciousness of 6 hours to 24 hours, Epidural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, Epidural hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, Epidural hemorrhage with loss of consciousness of unspecified duration, Traumatic subdural hemorrhage without loss of consciousness, Traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, Traumatic subdural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, S06.5X3S Traumatic subdural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, S06.5X4S S06.5X5S S06.5X6S S06.5X9S Traumatic subdural hemorrhage with loss of consciousness of 6 hours to 24 hours, Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours without return to preexisting conscious level with patient surviving, Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, S06.6X0S S06.6X1S Traumatic subarachnoid hemorrhage without loss of consciousness, Traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less, S06.6X2S Traumatic subarachnoid hemorrhage with loss of consciousness of 31 minutes to 59 minutes,

16 Page 16 of 20 S06.6X3S Traumatic subarachnoid hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, S06.6X4S Traumatic subarachnoid hemorrhage with loss of consciousness of 6 hours to 24 hours, S06.6X5S S06.6X6S S06.6X9S Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours with return to preexisting conscious level, Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours without return to preexisting conscious level with patient surviving, Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, S06.810S S06.811S S06.812S S06.813S S06.814S S06.815S Injury of right internal carotid artery, intracranial portion, not elsewhere classified without loss of consciousness, Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of 30 minutes or less, Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of 31 minutes to 59 minutes, Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of 1 hour to 5 hours 59 minutes, Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of 6 hours to 24 hours, Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness greater than 24 hours with return to pre-existing conscious level, S06.816S Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, S06.819S S06.820S S06.821S S06.822S S06.823S S06.824S S06.825S S06.826S Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of unspecified duration, Injury of left internal carotid artery, intracranial portion, not elsewhere classified without loss of consciousness, Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of 30 minutes or less, Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of 31 minutes to 59 minutes, Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of 1 hour to 5 hours 59 minutes, Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of 6 hours to 24 hours, Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness greater than 24 hours with return to pre-existing conscious level, Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving,

17 Page 17 of 20 S06.829S S06.890S S06.891S Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of unspecified duration, Other specified intracranial injury without loss of consciousness, Other specified intracranial injury with loss of consciousness of 30 minutes or less, S06.892S Other specified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, S06.893S Other specified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, S06.894S Other specified intracranial injury with loss of consciousness of 6 hours to 24 hours, S06.895S S06.896S S06.899S Other specified intracranial injury with loss of consciousness greater than 24 hours with return to preexisting conscious level, Other specified intracranial injury with loss of consciousness greater than 24 hours without return to preexisting conscious level with patient surviving, Other specified intracranial injury with loss of consciousness of unspecified duration, S06.9X0S S06.9X1S S06.9X2S Unspecified intracranial injury without loss of consciousness, Unspecified intracranial injury with loss of consciousness of 30 minutes or less, Unspecified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, S06.9X3S Unspecified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, S06.9X4S S06.9X5S S06.9X6S S06.9X9S Unspecified intracranial injury with loss of consciousness of 6 hours to 24 hours, Unspecified intracranial injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, Unspecified intracranial injury with loss of consciousness greater than 24 hours without return to preexisting conscious level with patient surviving, Unspecified intracranial injury with loss of consciousness of unspecified duration, References Abikoff H. Cognitive training in ADHD children: Less to it than meets the eye. J Learn Disabil. 1991;24: Agency for Healthcare Policy and Research (AHCPR). Rehabilitation for traumatic brain injury. AHCPR Evidence Report/Technology Assessment No.2. February Accessed January 28, Agency for Healthcare Research and Quality (AHRQ). Rehabilitation for traumatic brain injury in children and adolescents. Evidence Report/Technology Assessment No. 2. September Accessed January 28, Amato MP, Portaccio E, Zipoli V. Are there protective treatments for cognitive decline in MS? J Neurol Sci. 2006;245(1-2): American Academy of Neurology. Assessment: Neuropsychological testing of adults. Considerations for neurologists. Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 1996;47(2): American Academy of Neurology. Practice Parameters: Assessment and management of patients in the persistent vegetative state (Summary Statement). Report of the quality Standards Subcommittee of the American Academy of