RetiredCapital BluecrossPolicy MP 8.007

Cognitive rehabilitation

Defines medical necessity and coverage criteria for cognitive rehabilitation services for members with cognitive deficits due to neurologic injury; applies to Capital Blue Cross products with benefit variations.

Policy Summary

PayerCapital Bluecross

PolicyCognitive rehabilitation

Policy CodePolicy MP 8.007

Change TypeRetired

Effective DateRETIRED 11/1/2025

Next Review DateN/A

Key ActionDocument and justify cognitive rehabilitation with a written care plan and use listed ICD-10-CM diagnosis codes when requesting authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

97129,97130procedure codes covered

16-weekexample program duration

~50+ICD-10 codes listed

72+references cited

7policy history entries

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Coverage Criteria

Medically Necessary

Cognitive rehabilitation may be considered medically necessary when ALL of the following are met:

Member-level requirements: Member has documented potential for improvement; is able to actively participate in the program; and requires treatment of cognitive deficits acquired as a result of neurologic impairment due to documented traumatic brain injury, stroke, or encephalopathy.

Source: I. POLICY (chunks 1)

Service-level requirements: Cognitive rehabilitation is performed as a distinct and definable treatment; is prescribed and monitored by a qualified licensed professional; and is documented as part of a written care plan.

Source: II. POLICY (chunk 2)

Investigational / Insufficient Evidence

Not established/Investigational:

Other indications: Cognitive rehabilitation is considered investigational for all other applications beyond traumatic brain injury, stroke, or encephalopathy due to insufficient evidence to support general benefit.

Source: chunk 2

Dementia: Systematic reviews of RCTs have generally shown no benefit of cognitive rehabilitation for dementia; one large RCT reported some benefit on one of two functional scales and lower institutionalization at 24 months but these results need replication.

Source: chunk 9

Multiple sclerosis (MS): Systematic reviews of RCTs for MS have shown no significant effects on cognitive outcomes; trials are heterogeneous and high-quality durable benefit has not been established.

Source: chunk 10

Epilepsy, autism spectrum disorder, cancer: The quantity and quality of studies are limited for epilepsy, autism spectrum disorder, and cancer-related cognitive deficits; systematic reviews generally do not support efficacy and available RCTs have methodological limitations and short follow-up, so evidence is insufficient to determine benefit.

Source: chunk 10

This policy applies to cognitive rehabilitation when it is directed at treating cognitive deficits that are acquired as a result of neurologic impairment from documented traumatic brain injury, stroke, or encephalopathy. Coverage is contingent on both member- and service-level requirements: the member must have a documented potential for improvement and be able to actively participate, and the service must be performed as a distinct and definable treatment, prescribed and monitored by a qualified licensed professional, and documented as part of a written care plan.

This document is Capital Blue Cross Medical Policy MP 8.007, titled COGNITIVE REHABILITATION. The policy overview and administrative header identify the policy number and status; the policy was retired effective 11/1/2025 and includes standard sections for description/background, benefit variations, definitions, coding, and policy history.

Policy history notes that earlier revisions removed a detailed listing of investigational conditions: the record states that during the 03/07/2022 major review the policy stopped listing investigational conditions explicitly and revised guideline language and coding instead, so the current excerpt does not enumerate prior investigational-condition listings.

The policy considers cognitive rehabilitation for conditions outside of traumatic brain injury, stroke, or encephalopathy to be investigational or insufficiently supported. Specifically, systematic reviews and randomized trials provide mixed or insufficient evidence for use in dementia, and for multiple sclerosis, epilepsy, autism spectrum disorder, and cancer-related cognitive deficits the evidence is generally limited, heterogeneous, and does not support routine coverage.

Excerpted header material identifies the document as a Medical Policy and includes the policy title, number, core aims (assure prerequisites, appropriate care level/duration/site), and indicates policy sections for clinical benefit, description/background, benefit variations, references, definitions, and coding.

The provided excerpt does not include an explicit section labeled 'not medically necessary' for specific services; instead, the policy frames noncovered or investigational applications within the investigational/insufficient evidence language and via exclusions noted in the policy history and main policy statements.

Coding

Covered CPT CodesCPTCovered

97129
97130

Covered ICD-10 Diagnosis CodesICD-10Covered

I69.010	Attention and concentration deficit following nontraumatic subarachnoid hemorrhage.
I69.011	Memory deficit following nontraumatic subarachnoid hemorrhage.
I69.012	Visuospatial deficit and spatial neglect following nontraumatic subarachnoid hemorrhage.
I69.013	Psychomotor deficit following nontraumatic subarachnoid hemorrhage.
I69.014	Frontal lobe and executive function deficit following nontraumatic subarachnoid hemorrhage.
I69.015	Cognitive social or emotional deficit following nontraumatic subarachnoid hemorrhage.
I69.018	Other symptoms and signs involving cognitive functions following nontraumatic subarachnoid hemorrhage.
I69.110	Attention and concentration deficit following nontraumatic intracerebral hemorrhage.
I69.111	Memory deficit following nontraumatic intracerebral hemorrhage.
I69.112	Visuospatial deficit and spatial neglect following nontraumatic intracerebral hemorrhage.

1–10 of 36

1/4

ICD-10-CM codes (sequelae — cerebrovascular/intracerebral)ICD-10

I69.112	Visuospatial deficit and spatial neglect following nontraumatic intracerebral hemorrhage
I69.113	Psychomotor deficit following nontraumatic intracerebral hemorrhage
I69.114	Frontal lobe and executive function deficit following nontraumatic intracerebral hemorrhage
I69.115	Cognitive social or emotional deficit following nontraumatic intracerebral hemorrhage
I69.118	Other symptoms and signs involving cognitive functions following nontraumatic intracerebral hemorrhage
I69.210	Attention and concentration deficit following other nontraumatic intracranial hemorrhage
I69.211	Memory deficit following other nontraumatic intracranial hemorrhage
I69.212	Visuospatial deficit and spatial neglect following other nontraumatic intracranial hemorrhage
I69.213	Psychomotor deficit following other nontraumatic intracranial hemorrhage
I69.214	Frontal lobe and executive function deficit following other nontraumatic intracranial hemorrhage

1–10 of 21

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ICD-10-CM codes (R41 series and other cerebrovascular sequelae)ICD-10

I69.812	Visuospatial deficit and spatial neglect following other cerebrovascular disease
I69.813	Psychomotor deficit following other cerebrovascular disease
I69.814	Frontal lobe and executive function deficit following other cerebrovascular disease
I69.815	Cognitive social or emotional deficit following other cerebrovascular disease
I69.818	Other symptoms and signs involving cognitive functions following other cerebrovascular disease
R41.840	Attention and concentration deficit
R41.841	Cognitive communication deficit
R41.842	Visuospatial deficit
R41.843	Psychomotor deficit
R41.844	Frontal lobe and executive function deficit

1–10 of 11

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ICD-10-CM codes (S06 series — traumatic brain injury and intracranial injury sequelae)ICD-10

S06.0X0S	Concussion without loss of consciousness, sequela
S06.0X1S	Concussion with loss of consciousness of 30 minutes or less, sequela
S06.0X9S	Concussion with loss of consciousness of unspecified duration, sequela
S06.0XAS	Concussion with loss of consciousness status unknown, sequela
S06.1X0S	Traumatic cerebral edema without loss of consciousness, sequela
S06.1X1S	Traumatic cerebral edema with loss of consciousness of 30 minutes or less, sequela
S06.1X2S	Traumatic cerebral edema with loss of consciousness of 31 minutes to 59 minutes, sequela
S06.1X3S	Traumatic cerebral edema with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela
S06.1X4S	Traumatic cerebral edema with loss of consciousness of 6 hours to 24 hours, sequela
S06.1X5S	Traumatic cerebral edema with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela

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Policy-listed CPT/HCPCS code changesmixed

97129	Therapeutic interventions, cognitive function (added to policy)
97130	Therapeutic interventions, cognitive function (add-on) (added to policy)
97127	Therapeutic interventions, cognitive function (deleted from policy)
G0515	Prolonged services (deleted from policy)

Program intensity example

Low-intensity programs1–2 sessions per week, 30–60 minutes per session, typically for 4–10 weeks

Moderate-intensity group/individual mixExample: three 2-hour group sessions weekly plus three 1-hour individual sessions (total ~9 hours/week)

Comprehensive intensive programExample: 5 hours per day, 4 days per week for 16 weeks (outpatient comprehensive program)

Provider Actions & Requirements

Prior Authorization

Prior Authorization & Product-Specific Requirements

Prior authorization requirements vary by product and member benefit plan. Providers must verify coverage with the member's health benefit plan before initiating services; preauthorization may be required for some products administered by Capital Blue Cross.

Benefit determination is based on the applicable health benefit plan language; medical policy does not guarantee coverage.
FEP PPO members: refer to the FEP Medical Policy Manual for any product-specific prior authorization rules.

Billing Rule

Use Listed ICD-10-CM Codes for Authorization

Use the ICD-10-CM diagnosis codes listed in the policy when submitting authorization requests and claims. Coverage and authorization decisions may be linked to specific diagnosis codes for cognitive deficits and sequelae.

Examples include (not exhaustive): I69.112–I69.815 series (cognitive deficits following intracerebral hemorrhage/infarction), R41.841–R41.844, R41.89, and sequela codes for traumatic brain injury (S06.*S).
Failure to use the appropriate ICD-10-CM code that documents the cognitive deficit or sequela may result in denial or coverage delay.

Billing Rule

Use Current CPT Codes for Prior Authorization

Providers must submit current, valid CPT codes when requesting prior authorization or submitting claims. Policy history reflects coding updates; use the most up-to-date CPT codes in effect at the time of service.

Policy history: codes 97129 and 97130 were added; older codes such as 97127 and G0515 were deleted — use current codes only.
Using deleted or obsolete CPT codes on authorization requests or claims can lead to claim denials or processing delays.

Denial Risk

Triggers for Denial

Documented clinical criteria and evidence of need are required. Lack of required documentation is a common trigger for denial.

Denials may be issued if there is no documented potential for improvement, the member is unable to actively participate, or cognitive deficits are not documented.
Ongoing services must show demonstrated, objective continued improvement; absence of objective improvement may result in denial of continued therapy.

Documentation Required

Required Diagnosis Documentation

Required diagnosis documentation must clearly describe the cognitive deficits or sequelae and link them to an acceptable neurologic cause (e.g., traumatic brain injury, stroke, encephalopathy).

Written care plan documenting goals, measurable outcomes, and monitoring by a qualified licensed professional is required.
Include specific ICD-10-CM codes for the documented deficits (see policy code lists) and, when applicable, sequela codes (S06.*S).

Billing Rule

Coding Documentation & Coding-Related Denial Risk

Coding and billing must reflect current policy updates. Providers should ensure coding aligns with the most recent policy history and code additions/deletions.

Policy history notes additions of ICD-10 codes and CPT changes (e.g., addition of 97129/97130 and deletion of 97127/G0515).
Claims and authorization requests that do not reflect recent coding changes are at risk for denial or administrative correction.

Note

Provider Action Summary

When requesting authorization or submitting claims, providers should verify benefit coverage, use the policy-specified diagnosis and procedure codes, and include the required documentation to support medical necessity.

Confirm member-specific product rules and preauthorization requirements with Capital Blue Cross prior to treatment.
Ensure the written care plan, qualifying diagnosis codes, evidence of potential for improvement, and documentation of ability to actively participate are included with any authorization request.

Definitions

Cognitive — definition and scope

TermCognitive

DefinitionPertains to the mental processes of comprehension, judgment, memory, and reasoning.

ScopeDistinguished from emotional and volitional processes; relevant to assessment of ability to participate in rehabilitation programs.

Encephalopathy — definition and causes

TermEncephalopathy

DefinitionGeneralized brain dysfunction marked by varying degrees of impairment of speech, cognition, orientation, and arousal.

Common causesInfectious agents, metabolic or mitochondrial dysfunction, brain tumor or increased intracranial pressure, toxins, hypoxia/ischemia, chronic progressive trauma, and others.

ICD-10-CM sequela and cognitive deficit codes — explanation

Purpose of sequela codesICD-10-CM sequela codes denote persistent deficits occurring after the acute phase of brain injury or cerebrovascular events.

Clinical scopeCodes cover attention, memory, visuospatial, psychomotor, frontal/executive, and social/emotional cognitive deficits following intracerebral hemorrhage, cerebral infarction, other cerebrovascular disease, and traumatic intracranial injury.

Usage noteThese sequela codes should be documented on claims and clinical records to justify cognitive rehabilitation services for post-injury cognitive deficits.

Cognitive rehabilitation — definition and scope

DefinitionCognitive rehabilitation: therapeutic interventions aimed at improving cognitive function after neurologic injury or disease.

ProvidersMay be delivered by physicians, psychologists, physical, occupational, or speech therapists and is distinct from general occupational therapy.

Evidence and guidelinesSupported by randomized trials and systematic reviews across populations (brain tumor, stroke, TBI, cancer survivors) and referenced clinical guidelines (NICE, VA/DoD, AHA/ASA, etc.).

OpenPayer

Cognitive rehabilitation

Coverage Criteria

Coding

Provider Actions & Requirements

Background

Definitions