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:
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
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).
is a reasonable probability of improvement
patient is able to actively participate in the program
services are only considered necessary when there is documented and continued
objective improvement in function.
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).