Original Issue Date (Created): October 4, 2002 Most Recent Review Date (Revised): March 25, 2014 Effective Date: June 1, 2014 I. POLICY Cognitive rehabilitation may be considered medically necessary for treatment of the cognitive deficits acquired only as a result of neurologic impairment due to traumatic brain injury, stroke, or encephalopathy, and when performed as a distinct and definable component of a medically necessary comprehensive rehabilitation program (e.g., includes at least 3 hours per day of physical medicine treatment, speech therapy, and occupational therapy). Cognitive rehabilitation performed outside of a comprehensive rehabilitation program is considered investigational, as there is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with this procedure. Cognitive rehabilitation for the treatment of conditions, other than those described above, is considered investigational, as there is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with this procedure. Cross-references: MP- 8.011 Sensory Integration Therapy II. PRODUCT VARIATIONS [N] = No product variation, policy applies as stated [Y] = Standard product coverage varies from application of this policy, see below [N] Capital Cares 4 Kids [N] PPO [N] HMO [Y] SeniorBlue HMO* [Y] SeniorBlue PPO* [N] Indemnity [N] SpecialCare [N] POS [Y] FEP PPO** * Refer to Novitas Solutions Inc. (LCD) L27513 Physical Medicine & Rehabilitation Services, PT and OT for other neurological disease coverage. **Refer to FEP Medical Policy Manual MP- 8.03.10 Cognitive Rehabilitation. The FEP Medical Policy manual can be found at: www.fepblue.org Page 1
III. DESCRIPTION/BACKGROUND Cognitive rehabilitation (CR) (also known as cognitive therapy, cognitive retraining, cognitive remediation, and cognitive behavior therapy) is a therapeutic approach designed to improve cognitive functioning after central nervous system insult. It includes an assembly of therapy methods that retrain or alleviate problems caused by deficits in attention, visual processing, language, memory, reasoning, problem solving, and executive functions. Cognitive rehabilitation consists of tasks designed to reinforce or re-establish previously learned patterns of behavior or to establish new compensatory mechanisms for impaired neurologic systems. Cognitive rehabilitation may be performed by a physician, psychologist, or a physical, occupational, or speech therapist. Cognitive rehabilitation must be distinguished from occupational therapy. Occupational therapy describes rehabilitation that is directed at specific environments (i.e., home or work). In contrast, cognitive rehabilitation consists of tasks designed to develop the memory, language, and reasoning skills that can then be applied to specific environments. IV. DEFINITIONS. COGNITIVE pertains to the mental processes of comprehension, judgment, memory, and reasoning, as contrasted with emotional and volitional process. CUTANEOUS pertains to the skin. ENCEPHALOPATHY refers to generalized (i.e., not localized) brain dysfunction marked by varying degrees of impairment of speech, cognition, orientation, and arousal. GUSTATORY pertains to the sense of taste. KINESTHETIC refers to the perception of one's own body parts, weight, and movement. PROTOCOL refers to a written plan specifying the procedures to be followed in giving a particular examination, in conducting research, or in providing care for a particular condition. Page 2
V. BENEFIT VARIATIONS The existence of this medical policy does not mean that this service is a covered benefit under the member s contract. Benefit determinations should be based in all cases on the applicable contract language. Medical policies do not constitute a description of benefits. A member s individual or group customer benefits govern which services are covered, which are excluded, and which are subject to benefit limits and which require preauthorization. Members and providers should consult the member s benefit information or contact Capital for benefit information. VI. DISCLAIMER Capital s medical policies are developed to assist in administering a member s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any medical policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this medical policy and a member s benefit information, the benefit information will govern. Capital considers the information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law. VII. REFERENCES Cognitive Rehabilitation 1997 TEC Assessments; Tab 6 2008 TEC Assessment February 2008) BCBSA TEC policy: "Cognitive Rehabilitation for Traumatic Brain Injury in Adults". December 2002. Bowen A, Lincoln NB. Cognitive rehabilitation for spatial neglect following stroke Cochrane Database Syst Rev 2007; (2):CD003586. Cicerone KD, Mott T, Azulay J et al A randomized controlled trial of holistic neuropsychologic rehabilitation after traumatic brain injury Arch Phys Med Rehabil 2008; 89(12):2239-49. Department of Veterans Affairs, Department of Defense. VA/DoD clinical practice guideline for management of concussion/mild traumatic brain injury. Washington (DC): Department of Veteran Affairs, Department of Defense; 2009 Institute of Medicine, National Academies Press. Cognitive rehabilitation therapy for traumatic brain injury. 2011, October. [Website]: http://iom.edu/reports/2011/cognitive- Rehabilitation-Therapy-for-Traumatic-Brain-Injury-Evaluating-the-Evidence.aspx Accessed December 31, 2013. Kurz A, Thone-Otto A, Cramer B et al. CORDIAL: Cognitive rehabilitation and cognitivebehavioral treatment for early dementia in Alzheimer disease. Alzheimer Dis Assoc Disord 2011 [Epub ahead of print]. Nair RD, Lincoln NB. Cognitive rehabilitation for memory deficits following stroke Cochrane Database Syst Rev 2007; (3):CD002293. Page 3
Novitas Solutions Local Coverage Determination (LCD) L27513: Physical Medicine & Rehabilitation Services, PT and OT Effective06/13/13.. [Website]: http://www.novitassolutions.com/webcenter/faces/oracle/webcenter/page/scopedmd/sad60252a_5537_4c5d_93 50_ca405e36e159/Page6.jspx?wc.contextURL=%2Fspaces%2FMedicareJL&_afrLoop=154 4500748225000&wc.originURL=%2Fspaces%2FMedicareJL#%40%3F_afrLoop%3D1544 500748225000%26wc.originURL%3D%252Fspaces%252FMedicareJL%26wc.contextURL %3D%252Fspaces%252FMedicareJL%26_adf.ctrl-state%3Du4dtga8z_204 Accessed December 31, 2013. Martin M, Altgassen AM, Cameron MH, Zehnder F. Cognition-based interventions for healthy older people and people with mild cognitive impairment. Cochrane Database Syst Rev 2011; (1):CD006220 Sitzer DI, Twamley EJ, Jeste DW. Cognitive training in Alzheimer s disease: A meta-analysis of the literature. Acta Psychiatr Scand 2006; 114:75-90. Taber's Cyclopedic Medical Dictionary, 20 th edition VIII. CODING INFORMATION Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement. Covered when medically necessary: CPT Codes 97532 97533 Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved. ICD-9 Procedure codes Description 93.89 Rehabilitation, not elsewhere classified ICD-9-CM Diagnosis Description Code* 434.01 Cerebral thrombosis with cerebral infarction 434.11 Cerebral embolism with cerebral infarction 434.91 Unspecified cerebral artery occlusion with cerebral infarction 438.0 Late effects of Cerebrovascular disease (Cognitive deficits ) Page 4
768.70 Hypoxic-Ischemic Encepholopathy, Unspecified 768.71 Mild Hypoxic-Ischemic Encephalopathy 768.72 Moderate Hypoxic-Ischemic 768.73 Severe Hypoxic-Ischemic Encephalopathy 850.0 Concussion with no loss of consciousness 850.9 854.0 854.19 Intracranial injury of other and unspecified nature, without mention of open intracranial wound, unspecified state of consciousness 959.01 Head injury unspecified V15.52 Personal History of Traumatic Brain Injury *If applicable, please see Medicare LCD or NCD for additional covered diagnoses. The following ICD-10 diagnosis codes will be effective October 1, 2015 ICD-10-CM Diagnosis Description Code* I63.30 Cerebral infarct due to thrombosis of unspecified cerebral artery I63.311 I63.312 Cerebral infarct due to thrombosis R and L middle cerebral artery I63.319 Cerebral infarct due to thrombosis unspecified middle cerebral artery I63.321 I63.322 Cerebral infarct due to thrombosis R and L anterior cerebral artery I63.331 I63.332 Cerebral infarct due to thrombosis R and L posterior cerebral artery I63.339 Cerebral infarct due to thrombosis unspecified posterior cerebral artery I63.341 163.342 Cerebral infarct due to thrombosis of R and L cerebellar artery I63.349 Cerebral infarct due to thrombosis of unspecified cerebellar artery I63.39 Cerebral infarct due to thrombosis of other cerebral artery I63.6 Cerebral infarct due to cerebral venous thrombosis, nonpyogenic I66.01 I66.03 Occlusion and stenosis of left, right and bilateral middle cerebral arteries I66.09 Occlusion of unspecified middle cerebral artery I66.11 I66.13 Occlusion and stenosis of left, right and bilateral anterior cerebral artery I66.19 Occlusion and stenosis of unspecified anterior cerebral artery I66.21 I66.23 Occlusion and stenosis of left, right and bilateral posterior cerebral artery I66.29 Occlusion and stenosis of unspecified posterior cerebral artery I66.3 Occlusion and stenosis of cerebellar arteries Page 5
I66.9 Occlusion and stenosis of unspecified cerebellar arteries I69.01 Cognitive deficits following nontraumatic subarachnoid hemorrhage I69.11 Cognitive deficits following nontraumatic intracerebral hemorrhage I69.21 Cognitive deficits following nontraumatic following other intracranial hemorrhage I69.31 Cognitive deficits following cerebral Infarct I69.81 Cognitive deficits following other cerebrovascular disease I69.91 Cognitive deficits following unspecified cerebrovascular disease P91.60 Hypoxic ischemic encephalopathy [HIE], unspecified P91.61 Mild hypoxic ischemic encephalopathy [HIE] P91.62 Moderate hypoxic ischemic encephalopathy [HIE] P91.63 Severe hypoxic ischemic encephalopathy [HIE] S06.0x0a Concussion without loss of consciousness, initial encounter S06.890A Other specified intracranial injury without loss of consciousness, initial encounter. S09.10XA Unspecified injury of muscle and tendon of head, initial encounter S09.11XA Strain of muscle and tendon of head, initial encounter S09.19XA Other specified injury of muscle and tendon of head, initial encounter S09.8XXA Other injuries of head, initial encounter S09.90XA Unspecified injury of head, initial encounter Z87.820 Personal history of traumatic brain injury *If applicable, please see Medicare LCD or NCD for additional covered diagnoses. IX. POLICY HISTORY MP 8.007 CAC 2/25/03 CAC 9/28/04 CAC 9/27/05 CAC 11/29/05 CAC 10/31/06 CAC 11/27/07 CAC 11/25/08 CAC 9/29/09 Consensus Review CAC 9/28/10 Consensus Review CAC 10/25/11 Consensus Review. Added reference to MP 8.011 Sensory Integration Therapy. Deleted information related to Sensory Stimulation - retired. CAC 8/28/12 Consensus Review. No change to policy statements. References updated. Page 6
Codes reviewed 8/29/12 klr CAC 7/30/13 Consensus Review. No change to policy statements. Admin code review completed. CAC 3/25/14 Consensus review. References updated. No change to the policy statements. ICD9 Surgical codes added. Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company, Capital Advantage Assurance Company and Keystone Health Plan Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. Page 7