Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

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QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:



Effective Date: 01/01/2015	Title: Cognitive Rehabilitation
Revision Date: 11/01/2018	Document: BI456:00
CPT Code(s): None
Public Statement
*Effective Date:* a) This policy will apply to all services performed on or after the above Revision date which will become the new effective date. b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. Cognitive rehabilitation requires preauthorization. It is not covered for all plans; see your plan documents. Cognitive rehabilitation is a treatment modality designed specifically for the remediation of disorders of perception, memory and language in brain-injured persons. It is typically carried out in a residential treatment facility specifically designed to provide the service.
Medical Statement
1) Cognitive rehabilitation as a distinct and definable component of the rehabilitation process for treatment of functional deficits. It is covered only when all of these are met: a) For members who have sustained a severe traumatic brain injury with an extended period of unconsciousness or amnesia after the injury, or a Glasgow Coma Scale below 9 within the first 48 hours of injury, cerebral vascular insult (CVI) and brain injury due to stroke, aneurysm, anoxia, encephalitis, brain tumors, and brain toxins. b) Initial neuropsychological testing to identify functional deficits has been performed and a treatment plan with defined goals has been established. (Neuropsychological testing requires prior authorization. Please refer to BI005 for prior authorization criteria for neuropsychological testing). c) When there is a reasonable probability of improvement d) When the patient is able to actively participate in the program 2) Continued services are only considered necessary when there is documented and continued objective improvement in function. 3) Inpatient Cognitive Rehabilitation Therapy is covered only when a member also meets criteria for inpatient medical rehabilitation services (Please see BI433 for acute inpatient rehab criteria).
Limits
1) Cognitive rehabilitation has an annual limit as defined in your plan documents. 2) Cognitive rehabilitation is not covered for following: a) Cognitive Rehabilitation Therapy for any condition other than listed above; b) In-home Cognitive Rehabilitation Therapy; c) In assisted living facilities or residential living settings (It is covered in Skilled Nursing Facility); d) As part of community integration programs (services do not require the skills of a healthcare professional); e) Cognitive Behavioral Therapy (except for Covered Services for Mental Health Services); f) Coma stimulation; g) Cognitive Rehabilitative Therapy for member who is receiving custodial care.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

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