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    v1.0.28
    OpenPayerPolicy UpdatesPhysical Medicine, Rehab & TherapiesBCBS Vermont Cognitive Rehab Coverage | OpenPayer
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    CurrentBlue Cross Blue Shield of VermontPolicy 8.03.VT10

    Cognitive Rehabilitation Corporate Medical Policy

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    This policy governs coverage of cognitive rehabilitation as a distinct component of rehabilitation for members with moderate to severe traumatic brain injury or specified acquired brain injuries. It establishes medical-necessity criteria, investigational applications, eligible providers, and applicable diagnosis coding guidance.

    Policy Summary
    PayerBlue Cross Blue Shield of Vermont
    PolicyCognitive Rehabilitation Corporate Medical Policy
    Policy CodePolicy 8.03.VT10
    Change TypeNo material change
    Effective DateOct 1, 2026
    Last ReviewJun 1, 2026
    Next Review DateJun 1, 2027
    Key ActionDocument the attending physician's prescription and written treatment plan identifying cognitive rehabilitation as part of the rehabilitation program.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    7Specified brain injury conditions potentially eligible when criteria are met
    5Required medical-necessity conditions
    InvestigationalOther applications or cases failing any required condition
    Qualified licensed professional

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    Provider qualification requirement

    Medical Necessity and Investigational Applications

    Initial Cognitive Rehabilitation Medical Necessity

    Cognitive rehabilitation may be considered medically necessary for rehabilitation of moderate to severe traumatic brain injury or brain injury due to cerebrovascular accident (stroke), intracranial aneurysm, anoxia, encephalitis, brain tumors, or brain toxins when ALL of the following conditions are met.

    Medical-necessity criteria

    • Qualified provider: Cognitive rehabilitation is provided by a qualified licensed healthcare professional, such as an occupational therapist, physical therapist, speech/language pathologist, neuropsychologist, psychologist, psychiatrist, or other physician.
    • Physician prescription and treatment plan: Cognitive rehabilitation is prescribed by the attending physician as part of a written treatment plan.
    • Active participation: The member is able to actively participate in the program, with sufficient cognitive function to understand and participate and adequate language expression and comprehension; the member is not in a vegetative or comatose state and does not have severe aphasia.
    • Potential for improvement: Cognitive rehabilitation is expected to provide the potential for improvement based on the member's pre-injury function.
    • Continued objective improvement: The member demonstrates continued objective improvement in function once rehabilitation has commenced.

    Investigational Applications

    Cognitive rehabilitation is considered investigational when one or more medical-necessity conditions is not met or when it is used for other applications.

    Investigational applications

    • Failure to meet a medical-necessity condition: One or more required conditions is not met, including the qualified licensed provider, attending-physician prescription and written treatment plan, active participation capacity, potential for improvement based on pre-injury function, or continued objective improvement after rehabilitation begins.
    • Mild traumatic brain injury and concussion: Mild traumatic brain injury, concussion, or post-concussion syndrome.
    • Developmental and learning conditions: Attention deficit disorder, attention deficit hyperactivity disorder, developmental delay, learning disabilities, or prematurity.
    • Neurologic conditions:

    Cognitive rehabilitation is considered investigational when any required medical-necessity condition is not met or when it is provided for other applications. This includes mild traumatic brain injury, concussion, post-concussion syndrome, attention deficit disorder or attention deficit hyperactivity disorder, developmental delay, learning disabilities, prematurity, Parkinson's disease, multiple sclerosis, cerebral palsy, schizophrenia, pervasive developmental disorders or autism spectrum disorders, Alzheimer's disease, and other dementias. The policy states that insufficient evidence supports conclusions regarding effects on net health outcomes for these applications.

    Procedure and Diagnosis Coding

    Procedure and billing codes referenced in policy implementation historymixed
    97127Added to the ICD-10 tables in 06/2017; subsequently deleted and replaced by 97129 and 97130 effective 01/01/2020.
    97532Deleted in 01/2018.
    G0515Added in 01/2018; removed from the coding table because the code was deleted.
    99483Added in 01/2018; can only be reported every 180 days.
    97129Replaced 97127 effective 01/01/2020.
    97130Replaced 97127 effective 01/01/2020.
    96125Required prior approval if over 8 hours in 01/2020; the prior-approval requirement was removed in 03/2020.
    Diagnoses considered medically necessary when applicable criteria are metICD-10Covered
    S06.1XX-S06.9XXTraumatic brain injury, code range.
    I63.9Cerebral infarction (Stroke).
    I67.1Cerebral aneurysm (Intracranial).
    G93.1Anoxic brain damage, not elsewhere specified.
    G04.00-G04.02Encephalitis, code range.
    G92Toxic encephalopathy.
    C71.0-C71.9Brain Tumor(s) code range.
    D33.0-D33.2Brain Tumor(s) code range.
    D43.0-D43.2Brain Tumor(s) code range.
    D49.6Brain Tumor(s) code range.
    99483 Reporting Frequency
    Code99483
    Reporting frequencyEvery 180 days
    Policy historyAdded in 01/2018
    96125 Prior Approval
    Code96125
    Prior-approval thresholdOver 8 hours
    Requirement statusPrior-approval requirement removed in 03/2020

    Documentation and Denial-Risk Considerations

    Documentation Required

    Written Treatment Plan Required

    Document that cognitive rehabilitation is prescribed by the attending physician as part of a written treatment plan.

    Documentation Required

    Active Participation Capacity

    Document that the member can actively participate, with sufficient cognitive function to understand and participate in the program and adequate language expression and comprehension.

    • The member must not be in a vegetative or comatose state and must not have severe aphasia.
    Documentation Required

    Expected and Demonstrated Improvement

    Document that cognitive rehabilitation is expected to provide potential for improvement based on pre-injury function, and that the member demonstrates continued objective improvement in function after rehabilitation begins.

    Cognitive Rehabilitation Overview

    Cognitive rehabilitation is a structured set of therapeutic activities intended to improve or compensate for deficits in memory, attention, perception, learning, planning, judgment, and decision-making after a central nervous system insult. Treatment may reinforce previously learned behaviors or establish compensatory mechanisms for impaired neurologic systems, with goals focused on function and quality of life in the home and community. The policy recognizes possible medical necessity primarily for moderate to severe traumatic brain injury and specified acquired brain injuries.

    Policy Definitions

    Cognitive Rehabilitation
    DefinitionA structured set of therapeutic activities designed to retrain an individual's ability to think, use judgment, and make decisions following a central nervous system insult.
    Cognitive strategiesIntervention strategies or techniques intended to help reduce, manage, or cope with cognitive deficits caused by brain injury.
    Functional focusTasks may reinforce or reestablish previously learned patterns of behavior or establish new compensatory mechanisms for impaired neurologic systems.
    Active Participation
    Cognitive functionSufficient cognitive function to understand and participate in the program.
    Language abilityAdequate language expression and comprehension.
    Policy Summary
    PayerBlue Cross Blue Shield of Vermont
    PolicyCognitive Rehabilitation Corporate Medical Policy
    Policy CodePolicy 8.03.VT10
    Change TypeNo material change
    Effective DateOct 1, 2026
    Last ReviewJun 1, 2026
    Next Review DateJun 1, 2027
    Key ActionDocument the attending physician's prescription and written treatment plan identifying cognitive rehabilitation as part of the rehabilitation program.
    SourceLink
    On This Page
    Medical Necessity and Investigational ApplicationsProcedure and Diagnosis CodingDocumentation and Denial-Risk ConsiderationsCognitive Rehabilitation OverviewPolicy Definitions
    Parkinson's disease, multiple sclerosis, or cerebral palsy.
  1. Psychiatric and developmental disorders: Schizophrenia, pervasive developmental disorders, or autism spectrum disorders.
  2. Dementias: Alzheimer's disease or other dementias.
    3. Denial Risk

    Failure to Meet Medical-Necessity Conditions

    Cognitive rehabilitation is considered investigational when one or more medical-necessity conditions is not met, including failure to use a qualified licensed healthcare professional or failure to satisfy the prescribing, participation, improvement-potential, or continued-objective-improvement requirements.

    • Qualified professionals may include an occupational therapist, physical therapist, speech/language pathologist, neuropsychologist, psychologist, psychiatrist, or other physician.
    Denial Risk

    Excluded Clinical Applications

    Cognitive rehabilitation is considered investigational for applications other than rehabilitation of moderate to severe traumatic brain injury or brain injury due to cerebrovascular accident (stroke), intracranial aneurysm, anoxia, encephalitis, brain tumors, or brain toxins.

    • Excluded applications include mild traumatic brain injury, concussion, post-concussion syndrome, attention deficit disorder, attention deficit hyperactivity disorder, developmental delay, learning disabilities, prematurity, Parkinson's disease, multiple sclerosis, cerebral palsy, schizophrenia, pervasive developmental disorders, autism spectrum disorders, Alzheimer's disease, and other dementias.
    Participation limitationsThe member is not in a vegetative or comatose state and does not have severe aphasia.