| Effective Date:01/01/2015 |
Title:Cognitive Rehabilitation
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| Revision Date:11/01/2018
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Document:BI456:00
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| CPT Code(s):None
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Public Statement
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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.
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Medical Statement
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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).
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Limits
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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.
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Reference
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Intentially left empty
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Application to Products
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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.
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Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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