CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Cognitive Rehabilitation — Coverage Criteria

Policy governing medical necessity and coverage criteria for inpatient and outpatient cognitive rehabilitation services for Neighborhood Health Plan of Rhode Island members across specified lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCognitive Rehabilitation — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization using the provider portal forms or contact Provider Services and ensure a physician-ordered written plan of care with documentation of measurable functional goals.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Multiple Medicaid linesLines of business

TBI / Acute brain insult / CVASupported clinical indications

Physician order + planAuthorization preconditions

24/7 supervision when neededInpatient intensity

AnnualReview cadence

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Coverage and Medical Necessity Criteria

Initial Rehabilitation: Cognitive

Covered when ALL of the following are met

Physician order and plan: The service must be ordered by the attending physician and be part of a written plan of care

Member participation: The member must be willing and capable to participate in the treatment plan

Measurable gains potential: Documented potential to show measurable functional gains within a predetermined timeframe

History of compliance with the treatment plan

Medical suitability: The individual's mental and physical condition indicates significant potential for improvement and there is no lasting or major impediment (e.g., severe dementia) preventing progress

Behavioral health/substance abuse: If recent or current unresolved behavioral health issues or substance abuse exist, an active treatment program with demonstrated compliance must be integral to the proposed cognitive rehabilitation program

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

Treatment review: The treating physician should review the treatment plan to assess continued need and document objective evidence of progress

Inpatient Cognitive Rehabilitation Programs

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

All initial criteria: All of the initial cognitive rehabilitation criteria must be met

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

Intensity not available elsewhere: An alternative level of care cannot provide the intensity of services required for treatment of the cognitive deficits

Continued Treatment / Extension of Authorization

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

Interim goals met: Established interim goals are met

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

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

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

The evidence base for cognitive rehabilitation is limited to specific neurologic conditions. There is insufficient evidence in the published medical literature to support cognitive rehabilitation for any condition other than traumatic brain injury (TBI), acute brain insult, or cerebrovascular accident (CVA). Services proposed for other diagnoses are excluded from coverage for lack of supporting evidence.

Coma stimulation (therapies directed at comatose or minimally responsive patients after brain injury) is considered not medically necessary. The policy states that coma stimulation is unproven and lacks sufficient evidence to support its use in this population, and therefore coverage will not be provided for these services.

Provider Requirements and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required; providers should use the Authorization Request Forms found on the provider portal or contact Provider Services for assistance. A phone messaging system is available for requests/inquiries both during and outside of business hours. Providers can call 1-800-963-1001 for help.

Use the Authorization Request Forms on the provider portal (Providers > Provider Resources > Forms).
Covered codes and coding guidance: see the Authorization Quick Reference Guide.

Note

Level-of-care Requirement

For inpatient admission and continued stays, an alternative lower level of care must be unable to provide the required intensity of services for treatment of the cognitive deficits (e.g., 24/7 constant supervision needs due to poor judgment or safety concerns).

Covered Codes and Billing

Covered CPT CodesCPTCovered

97532

Cognitive Rehabilitation

Clinical Background

Cognitive rehabilitation refers to therapeutic activities designed to retrain cognitive abilities and help patients reduce, manage, or cope with cognitive deficits caused by brain injury. It aims to restore or compensate for impairments in areas such as attention, memory, problem‑solving, judgment, and decision‑making, and is typically delivered by a multidisciplinary team (for example, speech‑language pathology, occupational therapy, physical therapy, and neuropsychology) in individual or group formats.

The primary purpose of cognitive rehabilitation is to achieve measurable functional gains that permit improved independence and safer community participation. Programs are provided when there is documented potential for measurable improvement within a predetermined timeframe, the service is ordered by the attending physician and included in a written plan of care, the member is willing and capable of participation, and viable discharge alternatives are identified as part of planning.

Key Definitions

Cognitive rehabilitation — Therapeutic activities intended to retrain cognitive abilities and help patients reduce, manage, or cope with cognitive deficits caused by brain injury

DefinitionTherapeutic activities intended to retrain cognitive abilities and help patients reduce, manage, or cope with cognitive deficits caused by brain injury; may include techniques to learn alternative strategies when restoration to pre-injury level is not possible.

Delivery settingsMay be delivered inpatient or outpatient and performed individually or in groups based on patient needs.

Disciplines involvedMay include intensive therapy by speech-language pathologists, physical therapists, occupational therapists, and neuropsychologists.

Primary goalRestore or compensate for impaired thinking, judgment, and decision-making to improve functional outcomes.

When usedApplied after brain injury to address cognitive deficits; focuses on reduction, management, or coping strategies rather than guaranteed restoration.