CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Cognitive rehabilitation services

Defines coverage criteria, inpatient program requirements, continued-treatment criteria, exclusions, and authorization steps for cognitive rehabilitation for Neighborhood Health Plan of Rhode Island lines of business (HBE, RIte Care, CSN, SUB, RHP, Rhody). Applies Medicare distinction for INTEGRITY members and references therapy visit limits for outpatient therapists.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCognitive rehabilitation services

Policy CodePolicy N/A

Change Typeclarified

Effective Date

Next Review Date

Key ActionProviders must request authorization using Neighborhood's prior authorization forms via Provider Resources -> Forms or call 1-800-963-1001 for assistance.

POLICY UPDATE CHANGES

Annual review history and multiple review/approval dates are listed through 2/12/25.

3Covered primary indications

1Excluded treatment (coma stimulation)

11Recorded review/approval dates (2011-2025)

Coverage Summary

Cognitive rehabilitation comprises therapeutic activities delivered by speech-language pathologists, physical therapists, occupational therapists, and neuropsychologists to retrain thinking, judgment, and decision-making after brain injury. It may be delivered in either inpatient or outpatient settings and can be provided individually, in groups, or both.

Medical Necessity Criteria

General Medical Necessity Criteria for Cognitive Rehabilitation

All the following criteria must be met to qualify for rehabilitation: cognitive

ALL of the following

The service must be ordered by the attending physician and be part of a written plan of care
The member must be willing and capable to participate in the treatment plan
Documented potential to show measurable functional gains within a predetermined timeframe
History of compliance with treatment plan
The individual's mental and physical condition related to the injury indicates there is significant potential for improvement and the individual must have no lasting or major treatment impediment that prevents progress, such as severe dementia
If there is a recent or current history of unresolved behavioral health issues or substance abuse, an active treatment program with demonstrated compliance is an integral part of the proposed cognitive rehab program
Viable discharge placement alternatives are identified during the assessment for admission to the program
The treating physician should review the treatment plan to assess the continued need for participation and document objective evidence of progress
When cognitive rehabilitation is performed by physical, occupational and/or speech therapists as part of the outpatient rehabilitation therapy program for eligible patients, these services will be counted toward any applicable therapy visit limits (speech/OT/PT limits apply)

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Inpatient Cognitive Rehabilitation Programs - Additional Criteria

All of the above general criteria must be met as well as the following:

ALL of the following

Constant supervision 24/7 due to poor judgment and safety concerns is required
An alternative level of care cannot provide the intensity of services required for the treatment of the cognitive deficits

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Continued Treatment / Extension of Authorization

All of the following criteria must be met to extend authorization of a cognitive rehabilitation program:

ALL of the following

Established interim goals are met
Member demonstrates quantifiable rates of improvement in functional abilities
Evidence of compliance, willingness, and active participation in treatment program
An alternative level of care cannot provide the intensity of services required for the treatment of the cognitive deficits

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Not Covered / Exclusions

Excluded indications and denial risks: the policy states there is insufficient evidence to support cognitive rehabilitation for conditions other than traumatic brain injury (TBI), acute brain insult, or cerebrovascular accident (CVA), and such claims may be denied for lack of evidence. In addition, coma stimulation is explicitly identified as unproven and considered not medically necessary for comatose or minimally responsive patients due to insufficient evidence.

Not Covered / Experimental

Not Covered / Experimental — unsupported indications

Not Covered / Experimental: Claims for cognitive rehabilitation for conditions other than traumatic brain injury, acute brain insult, or CVA are considered unsupported by sufficient evidence; coma stimulation is unproven and considered not medically necessary for comatose or minimally responsive patients after brain injury.

Provider Actions & Billing

Prior Authorization

Authorization required / Prior authorization process

Providers must request prior authorization using Neighborhood's prior authorization forms available under Provider Resources -> Forms. A phone messaging system is in place for requests and inquiries both during and outside business hours; providers can call 1-800-963-1001 for assistance.

Documentation Required

Written plan of care and physician review

Services must be ordered by the attending physician and be part of a written plan of care. The treating physician should review the treatment plan to assess continued need for participation and must document objective evidence of progress for ongoing services.

Billing Rule

Therapy visit limits

When cognitive rehabilitation is provided by physical, occupational, and/or speech therapists as part of the outpatient rehabilitation therapy program for eligible patients, those services are counted toward any applicable therapy visit limits for PT/OT/speech.

Denial Risk

Exclusion for unsupported indications

Cognitive rehabilitation for conditions other than traumatic brain injury, acute brain insult, or CVA lacks sufficient evidence in the published literature and claims for those unsupported indications may be denied.

Background & Evidence

Cognitive rehabilitation consists of therapeutic techniques intended to reduce, manage, or help patients cope with cognitive deficits caused by brain injury; when functions cannot be restored to pre-injury levels, techniques may focus on learning to do things differently. Services may be intensive and are provided by speech-language pathologists, physical therapists, occupational therapists, and neuropsychologists.

Services can be provided in inpatient or outpatient settings and may be delivered individually or in groups depending on patient needs. The policy references CPT code 97532 (Cognitive Rehabilitation) and primary evidence sources including Cicerone KD reviews and RCTs, NIH consensus reports, and systematic reviews (e.g., Cochrane), as well as the Local Coverage Determination L29833.

Neighborhood applies CMS guidance for INTEGRITY (Medicare) members and, where CMS guidance is absent or incomplete, will use RI EOHHS or peer-reviewed scientific evidence to inform coverage determinations.

Definitions

Cognitive rehabilitationTherapeutic activities designed to retrain the individual's ability to think and use judgment to make decisions and manage cognitive deficits caused by brain injury.

INTEGRITY membersMedicare members for whom Neighborhood follows CMS guidance (NCDs, LCDs, LCAs) for coverage determinations; when Medicare guidance is lacking, RI EOHHS or peer-reviewed evidence is applied.

Primary evidence sources cited in the policy include: Cicerone KD evidence reviews and RCTs (2003–2011), NIH consensus statements on TBI rehabilitation, the Cochrane review by Turner-Stokes et al., Local Coverage Determination L29833, and CPT reference for 97532.

OpenPayer

Cognitive rehabilitation services

Coverage Summary

Medical Necessity Criteria

Not Covered / Exclusions

Coding

Provider Actions & Billing

Background & Evidence

Medicare Determinations

Revision History