CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Cognitive Rehabilitation — Coverage Criteria

Defines medical necessity, coverage criteria, and authorization guidance for inpatient and outpatient cognitive rehabilitation services for members of Neighborhood Health Plan of Rhode Island lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCognitive Rehabilitation — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateFeb 12, 2025

Key ActionSubmit prior authorization requests using Neighborhood's prior authorization process and forms; call 1-800-963-1001 for assistance if needed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3primary eligible diagnoses listed

Prior authauthorization pathway referenced

Vocational rehabexplicit exclusion

24+document review/approval dates recorded

Coverage criteria for cognitive rehabilitation

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Initial Cognitive Rehabilitation

Covered when ALL of the following are met

Primary eligibility: Diagnosis of TBI, acute brain insult, or acute CVA

Order and plan: Service ordered by the attending physician and part of a written plan of care

Ability to participate: Member willing and capable to participate in the treatment plan

Potential for measurable gain: Documented potential to show measurable functional gains within a predetermined timeframe

History of compliance with treatment plan

Pre-injury condition: Pre-injury mental and physical condition indicates significant potential for improvement and no major impediment preventing progress (e.g., severe dementia)

Behavioral health/substance use: If recent or current unresolved behavioral health issues or substance abuse exist, an active treatment program with demonstrated compliance must be part of the proposed program

Discharge planning: Viable discharge placement alternatives identified during assessment for admission to the program

Physician review: Treating physician should review the treatment plan to assess continued need and document objective evidence of progress

Inpatient Cognitive Rehabilitation

In addition to the initial criteria, ALL of the following must be met

Supervision needs: Constant supervision required 24/7 due to poor judgment and safety concerns

Level of care intensity: An alternative level of care cannot provide the intensity of services required for treatment of the cognitive deficits

Continued Treatment / Extension of Authorization

To extend authorization ALL of the following must be met

Interim goals: Established interim goals are met

Quantifiable improvement: Member demonstrates quantifiable rates of improvement on functional abilities

Evidence of compliance: ability, willingness, and active participation in treatment program

No alternative care: An alternative level of care cannot provide the intensity of services required for treatment of the cognitive deficits

Coverage for cognitive rehabilitation is limited. There is insufficient evidence to support cognitive rehabilitation for conditions other than traumatic brain injury (TBI), acute brain insult, or cerebrovascular accident (CVA). Programs or services whose primary focus is vocational rehabilitation are excluded from coverage and may be denied if vocational goals are the main intent of the treatment plan. Providers should ensure the program’s documented goals and interventions are restorative or compensatory cognitive therapies addressing the eligible diagnoses, not primarily job-training or return-to-work activities.

Authorization, documentation, and provider requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required — Prior authorization requests must be submitted using Neighborhood's prior authorization process and forms. Access forms and submission instructions at www.nhpri.org (Providers > Provider Resources > Forms > prior authorization request forms). For assistance call 1-800-963-1001.

Refer to the Authorization Quick Reference Guide for covered codes.

Note

Medicare Guidance Hierarchy

For INTEGRITY (Medicare) members, CMS guidance (NCDs, LCDs, LCAs, and other CMS published guidance) takes precedence for coverage and medical necessity determinations. If Medicare guidance is absent or incomplete, Neighborhood will apply Rhode Island EOHHS guidance, peer-reviewed evidence (e.g., InterQual®), and internal Clinical Medical Policies.

Documentation Required

Required Documentation

Services must be ordered by the attending physician and be part of a written plan of care. Documentation must demonstrate measurable functional improvement, show established interim goals and quantifiable rates of improvement, and evidence of member compliance and ability/willingness to participate. The treating physician should review the treatment plan to assess continued need and document objective progress.

Must document potential to show measurable functional gains within a predetermined timeframe.
Continued treatment requires established interim goals met and quantifiable functional improvement.
Therapist-provided cognitive rehab (PT/OT/Speech) counts toward applicable outpatient therapy visit limits.

Denial Risk

Vocational Rehabilitation Exclusion

Vocational rehabilitation is not a covered benefit. If the primary focus of a cognitive rehabilitation program is vocational rehabilitation, the service will be denied/not covered.

Exclude programs primarily focused on job training, employment placement, or other vocational goals.

Background and clinical context

Cognitive rehabilitation comprises therapeutic activities delivered in inpatient or outpatient settings that aim to retrain cognitive skills and teach compensatory strategies after brain injury. It may be provided individually or in groups by disciplines such as speech-language pathology, occupational therapy, physical therapy, and neuropsychology. The approach focuses on reducing, managing, or compensating for deficits in thinking, memory, judgment, problem-solving, and decision-making, with measurable functional goals documented in a written plan of care.

Definitions

Cognitive rehabilitation — Definition and modalities (individual/group, disciplines involved)

DefinitionTherapeutic activities delivered inpatient or outpatient to retrain thinking, judgment, and decision-making after brain injury; techniques aim to reduce, manage, or compensate for cognitive deficits and teach alternate strategies when pre-injury function cannot be restored.

Delivery modalitiesMay be performed individually, in groups, or both depending on patient needs.

Therapy disciplines involvedMay include intensive services by speech-language pathologists, physical therapists, occupational therapists, and neuropsychologists.

Treatment goalsHelp patients reduce, manage, or cope with cognitive deficits and learn alternate strategies when restoration to pre-injury function is not possible.

Care settingDelivered in inpatient or outpatient settings based on clinical needs and program intensity requirements.