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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyQualChoice ABI Inpatient Neurorehab Coverage | Ope…
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    CurrentQualChoicePolicy AR.CP.MP.501

    Clinical Policy: Acquired Brain Injury (Subacute and Chronic) Inpatient Neurorehabilitation

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    Defines medical necessity criteria, documentation, admission, continued stay, and discharge requirements for subacute and chronic inpatient neurorehabilitation for acquired brain injury across Arkansas Plans (QualChoice, Ambetter from Arkansas Health and Wellness, Arkansas Total Care, and QualChoice commercial plans).

    Policy Summary
    PayerQualChoice
    PolicyAcquired Brain Injury (Subacute and Chronic) Inpatient Neurorehabilitation
    Policy CodePolicy AR.CP.MP.501
    Change TypeNo material changes
    Effective DateAug 1, 2025
    Last ReviewJun 16, 2025
    Next Review DateJun 16, 2025
    Key ActionObtain prior authorization and submit appropriate ICD-10 diagnosis codes and required documentation demonstrating medical necessity (referral, evaluations, plan of care, and evidence of need for at least two services).
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    3+ hrs/dayTherapy intensity
    2+ servicesRequired services on admission
    WeeklyPhysician oversight

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Revenue
    Billing method
    20+ICD-10 codes listed

    Medical Necessity — Admission, Continued Stay, and Exclusions

    Admission Criteria (Medically Necessary)

    Admission is medically necessary when ALL of the following are met:

    Admission general: Member meets documentation requirements; referral and diagnosis of Acquired Brain Injury (ABI) from a primary care provider, neurologist, rehabilitation specialist, or recent inpatient stay; condition is one of the listed ABI diagnoses.

    Conditions include: moderate or severe traumatic brain injury; viral encephalitis; meningitis; aneurysms or vascular disease affecting the brain; cerebral vascular accident (stroke); brain tumors (including post-operative) with neurological impairment; anoxic or hypoxic brain injury; toxic encephalopathies; refractory seizure disorders; brain injury from metabolic or endocrine disease; (for ARTC only) congenital neurologic brain disorders or anoxic brain injury during birth.

    Required services: Member requires at least two services: at minimum one intensive rehabilitative service (physical therapy, speech therapy, occupational therapy, or cognitive therapy) AND at least one additional service (behavioral/neurobehavioral rehabilitation, individual or group counseling, or life skills training).

    At least one of PT, ST, OT, or cognitive therapy plus at least one of behavioral/neurobehavioral rehab, counseling, or life skills training.

    Indications of need: Member has at least two of the following indications of need for a higher level of care: inability to maintain ADLs/IADLs independently at home within the last 30 days with failure of outpatient ABI therapy; OR at least two behavioral/mood symptoms that impair community function with failed outpatient treatment within the last 30 days; OR member safety in the community is threatened by listed factors; OR complexity of care not appropriate for outpatient setting; OR unable to attend school, work, or function in a structured environment within the last 30 days.

    Behavioral symptoms examples include aggression/hostility/intimidation, harmful behaviors to self or others (emotional outbursts, destruction of property, self-injury), severe social withdrawal, problematic sexual behavior, co-occurring substance use disorder with high relapse risk (ASAM criteria).

    Continued Stay Criteria (Medically Necessary)

    Continued inpatient neurorehabilitation is medically necessary when ALL of the following are met:

    Progress: Measurable and sustained progress toward plan-of-care goals in at least two areas (for example: ADLs/IADLs/life skills, functional mobility, speech therapy, cognitive rehabilitation, behavioral/neurobehavioral rehabilitation).

    Functional gains have not met maximum potential; gains over the past 7 days have been beyond a minimal level, and goals continue to show progress rather than plateauing.

    Therapy participation: Member continues to participate in rehabilitative treatment at an intensity of at least 3 hours per day, 5 days per week.>= 3 hours/day, 5 days/week

    Therapy must be integrated per the plan of care and documented in progress notes.

    Physician oversight and stability: Physician oversight with at least one progress note or physician visit per week; functional gains are ongoing (not at maximum potential) or behavioral symptoms continue to require facility-level intervention.

    Not Medically Necessary (Exclusion) Conditions

    Admission or continued stay is not medically necessary for any of the following:

    Acute/unstable medical conditions: Presence of acute medical problems, medically unstable condition, or communicable disease on admission or present for more than 3 calendar days during admission; requirement for mechanical ventilator; requirement for nutrition via intravenous administration.

    These conditions preclude inpatient neurorehabilitation until resolved/stabilized.

    Care level and participation: Care that is custodial, residential, or long-term nursing care; member not mentally or physically capable of participating in an intensive rehabilitation program (3 hours/day, 5 days/week); member is independent for self-care, mobility, and safety in the community; member has adapted to impairment with compensatory strategies or assistive devices; member can perform ADLs with minimal or no assistance when ADL improvement was a treatment goal.

    If the service requested is custodial or therapy is not required to safely provide care, inpatient neurorehabilitation is not medically necessary.

    Max benefit achieved or inability to benefit: Member has achieved maximum functional or behavioral benefit from inpatient treatment and is expected to benefit from outpatient services; or member is unable to participate in the treatment plan due to medical, psychological, or social complications and therapist skills are not required to provide or supervise the service.

    Diagnosis coding requirement

    Diagnosis codes and encounter/status modifiers listed in this section

    Diagnosis descriptor mapping: Claims and authorization requests must use the appropriate S0-series diagnosis code descriptors (as listed) that correspond to the clinical presentation, including loss-of-consciousness (LOC) duration and encounter type (initial, subsequent, sequela).

    Examples in this section include multiple S06x and related codes with LOC categories (e.g., 1–5 hrs 59 min, 6–24 hrs, >24 hrs, unspecified) and encounter/status modifiers; providers should map clinical findings to the exact S-code descriptor when submitting claims.

    The policy explicitly lists several conditions that render inpatient neurorehabilitation admission or continued stay not medically necessary. These include requirement for mechanical ventilation, requirement for nutrition via intravenous administration, and situations where care is custodial, residential, or long-term nursing care rather than skilled rehabilitation.

    Certain portions of the document present lists of diagnosis codes (for example, infectious meningitis and related conditions) without pairing each code to a separate explicit coverage decision or inclusion/exclusion statement. Use these code lists to select appropriate ICD-10-CM codes when submitting authorization or claims but recognize the code listings in isolation do not themselves state coverage determinations.

    Several chunks contain diagnostic code descriptors only (S-series trauma and skull fracture codes among others). These segments are limited to code identifiers and descriptions and do not include medical necessity language or coverage rules; they should be used for accurate documentation and claims coding rather than as standalone coverage directives.

    Within the supplied S‑code and traumatic hemorrhage sections there are no standalone policy exclusions stated. The content is descriptive code mapping (encounter type, loss‑of‑consciousness duration, sequela) and does not by itself list additional explicit exclusions.

    State Medicaid and other applicable state/federal requirements take precedence where they conflict with this clinical policy. This policy is intended as a medical necessity guide to assist coverage decisions; it is not a contract or guarantee of payment and providers should follow the member's coverage documents and plan administrative policies when requesting authorization or submitting claims.

    The policy identifies a set of conditions that are considered not medically necessary for inpatient neurorehabilitation. Key examples include medical instability or acute medical problems, inability to participate in an intensive program (defined elsewhere as 3 hours/day, 5 days/week), and situations where the member is effectively independent in self‑care or has achieved plan goals or plateaued. Custodial care or long‑term nursing needs are also listed as not medically necessary for inpatient rehabilitation.

    The S‑series and related code listings included in this excerpt do not contain explicit statements labeling any listed diagnosis as not medically necessary. They function as diagnostic descriptors to be applied to documentation and claims; clinical determinations about medical necessity must reference the policy’s admission and continued‑stay criteria.

    Diagnosis and Billing Codes

    Inpatient billing methodmixed
    revenue codesInpatient stays are revenue code based; CPT/HCPCS do not apply.
    ICD-10-CM Diagnosis Codes that Support Coverage CriteriaICD-10Covered
    T36.0+–T36.5+Poisoning and toxic effects supported by documentation of resulting acquired brain injury
    S0990XAUnspecified injury of head, initial encounter
    S0990XDUnspecified injury of head, subsequent encounter
    S0990XSUnspecified injury of head, sequela
    S028XXAFractures of oth skull and facial bones, init for clos fx
    S0291XAUnspecified fracture of skull, init encntr for closed fracture
    A0101Typhoid meningitis
    A0221Salmonella meningitis
    A066Amebic brain abscess
    A170Tuberculous meningitis
    1–10 of 98
    1/10
    Infectious meningitis/meningoencephalitis codes (sample)ICD-10
    B2782Cytomegaloviral mononucleosis with meningitis
    B2792Infectious mononucleosis, unspecified with meningitis
    B375Candidal meningitis
    Infectious and neoplasm of brain/meninges (sample)ICD-10
    B384Coccidioidomycosis meningitis
    B4081Blastomycotic meningoencephalitis
    B4281Cerebral sporotrichosis
    B431Pheomycotic brain abscess
    B451Cerebral cryptococcosis
    B461Rhinocerebral mucormycosis
    B500Plasmodium falciparum malaria with cerebral complications
    B5741Meningitis in Chagas' disease
    B5742Meningoencephalitis in Chagas' disease
    B582Toxoplasma meningoencephalitis
    1–10 of 14
    1/2
    Malignant brain neoplasm codesICD-10
    C710Malignant neoplasm of cerebrum, except lobes and ventricles
    C711Malignant neoplasm of frontal lobe
    C712Malignant neoplasm of temporal lobe
    C713Malignant neoplasm of parietal lobe
    C714Malignant neoplasm of occipital lobe
    C715Malignant neoplasm of cerebral ventricle
    C716Malignant neoplasm of cerebellum
    C717Malignant neoplasm of brain stem
    C718Malignant neoplasm of overlapping sites of brain
    C719Malignant neoplasm of brain, unspecified
    1–10 of 13
    1/2
    Benign neoplasm and additional infectious meningitis codesICD-10
    D320Benign neoplasm of cerebral meninges
    D321Benign neoplasm of spinal meninges
    D329Benign neoplasm of meninges, unspecified
    D330Benign neoplasm of brain, supratentorial
    D331Benign neoplasm of brain, infratentorial
    G000Hemophilus meningitis
    G001Pneumococcal meningitis
    G002Streptococcal meningitis
    G003Staphylococcal meningitis
    Encephalitis/meningitis codesICD-10
    G030Nonpyogenic meningitis
    G031Chronic meningitis
    G032Benign recurrent meningitis [Mollaret]
    G039Meningitis, unspecified
    G0400Acute disseminated encephalitis and encephalomyelitis, unsp
    G0430Bacterial meningoencephalitis and meningomyelitis, NEC
    G0431Acute necrotizing hemorrhagic encephalopathy, unspecified
    G0481Other encephalitis and encephalomyelitis
    G0490Encephalitis and encephalomyelitis, unspecified
    Abscess, hydrocephalus, and related codesICD-10
    G060Intracranial abscess and granuloma
    G062Extradural and subdural abscess, unspecified
    G213Postencephalitic parkinsonism
    G361Acute and subacute hemorrhagic leukoencephalitis [Hurst]
    G910Communicating hydrocephalus
    G911Obstructive hydrocephalus
    G912(Idiopathic) normal pressure hydrocephalus
    G913Post-traumatic hydrocephalus, unspecified
    G919Hydrocephalus, unspecified
    Anoxic encephalopathy and hemorrhage codesICD-10
    G931Anoxic brain damage, not elsewhere classified
    G9340Encephalopathy, unspecified
    G936Cerebral edema
    I6000Nontraumatic subarachnoid hemorrhage from unspecified carotid siphon and bifurcation
    I6010Nontraumatic subarachnoid hemorrhage from unspecified middle cerebral artery
    I602Nontraumatic subarachnoid hemorrhage from anterior communicating artery
    Cerebral infarction / ischemia codesICD-10
    I6300Cerebral infarction due to thrombosis of unspecified precerebral artery
    I6310Cerebral infarction due to embolism of unspecified precerebral artery
    I6320Cerebral infarction due to unspecified occlusion or stenosis of unspecified precerebral artery
    I6330Cerebral infarction due to thrombosis of unspecified cerebral artery
    I6340Cerebral infarction due to embolism of unspecified cerebral artery
    I6350Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery
    Vascular and occlusion codesICD-10
    I636Cerebral infarction due to cerebral venous thrombosis, nonpyogenic
    I638Other cerebral infarction
    I639Cerebral infarction, unspecified
    I6501Occlusion and stenosis of right vertebral artery
    I651Occlusion and stenosis of basilar artery
    I670Dissection of cerebral arteries, nonruptured
    Sequelae of hemorrhage and related functional deficitsICD-10
    I6900Unspecified sequelae of nontraumatic subarachnoid hemorrhage
    I6901Cognitive deficits following nontraumatic subarachnoid hemorrhage
    I69010Attention and concentration deficit following nontraumatic subarachnoid hemorrhage
    I69011Memory deficit following nontraumatic subarachnoid hemorrhage
    I6910Unspecified sequelae of nontraumatic intracerebral hemorrhage
    I6911Cognitive deficits following nontraumatic intracerebral hemorrhage
    I69120Aphasia following nontraumatic intracerebral hemorrhage
    I69121Dysphasia following nontraumatic intracerebral hemorrhage
    I69122Dysarthria following nontraumatic intracerebral hemorrhage
    Skull/occipital condyle fracture codes (partial)ICD-10
    S0211BSType I occipital condyle fracture, left side, sequela.
    S0211CAType II occipital condyle fracture, right side, init.
    S0211CBType II occipital condyle fracture, right side, 7thB.
    S0211CDType II occipital condyle fracture, right side, 7thD.
    S0211CGType II occipital condyle fracture, right side, 7thG.
    S0211CKType II occipital condyle fracture, right side, 7thK.
    S0211CSType II occipital condyle fracture, right side, sequela.
    S0211DAType II occipital condyle fracture, left side, init.
    S0211DBType II occipital condyle fracture, left side, 7thB.
    S0211DDType II occipital condyle fracture, left side, 7thD.
    Occipital condyle fracture codes continued (partial)ICD-10
    S0211EAType III occipital condyle fracture, right side, init.
    S0211EBType III occipital condyle fracture, right side, 7thB.
    S0211EDType III occipital condyle fracture, right side, 7thD.
    S0211EGType III occipital condyle fracture, right side, 7thG.
    S0211EKType III occipital condyle fracture, right side, 7thK.
    S0211ESType III occipital condyle fracture, right side, sequela.
    S0211FAType III occipital condyle fracture, left side, init.
    S0211FBType III occipital condyle fracture, left side, 7thB.
    S0211FDType III occipital condyle fracture, left side, 7thD.
    S0211FGType III occipital condyle fracture, left side, 7thG.
    Other occiput fracture codes (partial)ICD-10
    S0211FKType III occipital condyle fracture, left side, 7thK.
    S0211FSType III occipital condyle fracture, left side, sequela.
    S0211GAOther fracture of occiput, right side, init.
    S0211GBOther fracture of occiput, right side, 7thB.
    S0211GDOther fracture of occiput, right side, 7thD.
    S0211GGOther fracture of occiput, right side, 7thG.
    S0211GKOther fracture of occiput, right side, 7thK.
    S0211GSOther fracture of occiput, right side, sequela.
    S0211HAOther fracture of occiput, left side, init.
    Orbital roof fracture codes (partial)ICD-10
    S02121AFracture of orbital roof, right side, init.
    S02121BFracture of orbital roof, right side, 7thB.
    S02121DFracture of orbital roof, right side, 7thD.
    S02121GFracture of orbital roof, right side, 7thG.
    S02121KFracture of orbital roof, right side, 7thK.
    S02121SFracture of orbital roof, right side, sequela.
    S02122AFracture of orbital roof, left side, init.
    S02122BFracture of orbital roof, left side, 7thB.
    S02122DFracture of orbital roof, left side, 7thD.
    Concussion codes (S06.0 series, partial)ICD-10
    S060X0AConcussion without loss of consciousness, initial encounter.
    S060X0DConcussion without loss of consciousness, subs encntr.
    S060X0SConcussion without loss of consciousness, sequela.
    S060X1AConcussion w LOC of 30 minutes or less, init.
    S060X1DConcussion w LOC of 30 minutes or less, subs.
    S060X1SConcussion w LOC of 30 minutes or less, sequela.
    S060X2AConcussion w LOC of 31-59 min, init.
    S060X2DConcussion w LOC of 31-59 min, subs.
    S060X2SConcussion w LOC of 31-59 min, sequela.
    Traumatic cerebral edema codes (S06.1 series, partial)ICD-10
    S061X0ATraumatic cerebral edema w/o loss of consciousness, init.
    S061X0DTraumatic cerebral edema w/o loss of consciousness, subs.
    S061X0STraumatic cerebral edema w/o loss of consciousness, sequela.
    S061X1ATraumatic cerebral edema w LOC of 30 minutes or less, init.
    S061X1DTraumatic cerebral edema w LOC of 30 minutes or less, subs.
    S061X1STraum cerebral edema w LOC of 30 minutes or less, sequela.
    Diffuse and focal TBI codes (S06.2–S06.3 series, partial)ICD-10
    S062X0ADiffuse TBI w/o loss of consciousness, init.
    S062X0DDiffuse TBI w/o loss of consciousness, subs.
    S062X0SDiffuse TBI w/o loss of consciousness, sequela.
    S062X1ADiffuse TBI w LOC of 30 minutes or less, init.
    S062X1DDiffuse TBI w LOC of 30 minutes or less, subs.
    S062X1SDiffuse TBI w LOC of 30 minutes or less, sequela.
    S06300AUnsp focal TBI w/o loss of consciousness, init.
    Contusion/laceration codes (partial)ICD-10
    S06310AContus/lac right cerebrum w/o loss of consciousness, init.
    S06310DContus/lac right cerebrum w/o loss of consciousness, subs.
    S06310SContus/lac right cerebrum w/o loss of consciousness, sequela.
    S06311AContus/lac right cerebrum w LOC of 30 minutes or less, init.
    S06311DContus/lac right cerebrum w LOC of 30 minutes or less, subs.
    S06311SContus/lac right cerebrum w LOC of 30 minutes or less, sequela.
    S06312AContus/lac right cerebrum w LOC of 31-59 min, init.
    Contusion and traumatic hemorrhage codes (partial)ICD-10
    S06320AContus/lac left cerebrum w/o loss of consciousness, init.
    S06321AContus/lac left cerebrum w LOC of 30 minutes or less, init.
    S06330AContus/lac cereb, w/o loss of consciousness, init.
    S06333AContus/lac cereb, w LOC of 1-5 hrs 59 min, init.
    S06334AContus/lac cereb, w LOC of 6 hours to 24 hours, init.
    S06340ATraum hemor right cerebrum w/o loss of consciousness, init.
    S06345ATraum hemor r cereb w LOC >24 hr w ret consc lev, init.
    Contusion/laceration cerebral codesICD-10
    S06333SContus/lac cereb, w LOC of 1-5 hrs 59 min, sequela.
    S06334AContus/lac cereb, w LOC of 6 hours to 24 hours, init.
    S06334DContus/lac cereb, w LOC of 6 hours to 24 hours, subs.
    S06334SContus/lac cereb, w LOC of 6 hours to 24 hours, sequela.
    S06335AContus/lac cereb, w LOC >24 hr w ret consc lev, init.
    S06335DContus/lac cereb, w LOC >24 hr w ret consc lev, subs.
    S06335SContus/lac cereb, w LOC >24 hr w ret consc lev, sequela.
    S06336AContus/lac cereb, w LOC >24 hr w/o ret consc w surv, init.
    S06336DContus/lac cereb, w LOC >24 hr w/o ret consc w surv, subs.
    S06336SContus/lac cereb, w LOC >24 hr w/o ret consc w surv, sequela.
    1–10 of 16
    1/2
    Right cerebrum traumatic hemorrhage codesICD-10
    S06340ATraum hemor right cerebrum w/o loss of consciousness, init.
    S06340DTraum hemor right cerebrum w/o loss of consciousness, subs.
    S06340STraum hemor right cerebrum w/o LOC, sequela.
    S06341ATraum hemor right cerebrum w LOC of 30 minutes or less, init.
    S06341DTraum hemor right cerebrum w LOC of 30 minutes or less, subs.
    S06341STraum hemor r cereb w LOC of 30 minutes or less, sequela.
    S06342ATraum hemor right cerebrum w LOC of 31-59 min, init.
    S06342DTraum hemor right cerebrum w LOC of 31-59 min, subs.
    S06342STraum hemor right cerebrum w LOC of 31-59 min, sequela.
    Right cerebrum traumatic hemorrhage continuedICD-10
    S06343ATraum hemor right cerebrum w LOC of 1-5 hrs 59 minutes, init.
    S06343DTraum hemor right cerebrum w LOC of 1-5 hrs 59 minutes, subs.
    S06343STraum hemor r cereb w LOC of 1-5 hrs 59 minutes, sequela.
    S06344ATraum hemor right cerebrum w LOC of 6-24 hrs, init.
    S06344DTraum hemor right cerebrum w LOC of 6-24 hrs, subs.
    S06344STraum hemor right cerebrum w LOC of 6-24 hrs, sequela.
    S06345ATraum hemor r cereb w LOC >24 hr w ret consc lev, init.
    S06345DTraum hemor r cereb w LOC >24 hr w ret consc lev, subs.
    S06345STraum hemor r cereb w LOC >24 hr w ret consc lev, sequela.
    Additional right cerebrum hemorrhage codesICD-10
    S06346ATraum hemor r cereb w LOC >24 hr w/o ret consc w surv, init.
    S06346DTraum hemor r cereb w LOC >24 hr w/o ret consc w surv, subs.
    S06346STraum hemor r cereb w LOC >24 hr w/o ret consc w surv, sequela.
    S06349ATraum hemor right cerebrum w LOC of unsp duration, init.
    S06349DTraum hemor right cerebrum w LOC of unsp duration, subs.
    S06349STraum hemor right cerebrum w LOC of unsp duration, sequela.
    S0634AATraum hemor right cerebrum with LOC status unknown, init.
    S0634ADTraum hemor right cerebrum with LOC status unknown, subs.
    S0634ASTraum hemor right cerebrum with LOC status unknown, sequela.
    Left cerebrum traumatic hemorrhage codesICD-10
    S06350ATraum hemor left cerebrum w/o loss of consciousness, init.
    S06350DTraum hemor left cerebrum w/o loss of consciousness, subs.
    S06350STraum hemor left cerebrum w/o loss of consciousness, sequela.
    S06351ATraum hemor left cerebrum w LOC of 30 minutes or less, init.
    S06351DTraum hemor left cerebrum w LOC of 30 minutes or less, subs.
    S06351STraum hemor l cereb w LOC of 30 minutes or less, sequela.
    S06352ATraum hemor left cerebrum w LOC of 31-59 min, init.
    S06352DTraum hemor left cerebrum w LOC of 31-59 min, subs.
    S06352STraum hemor left cerebrum w LOC of 31-59 min, sequela.
    Left cerebrum traumatic hemorrhage continuedICD-10
    S06353ATraum hemor left cerebrum w LOC of 1-5 hrs 59 minutes, init.
    S06353DTraum hemor left cerebrum w LOC of 1-5 hrs 59 minutes, subs.
    S06353STraum hemor left cerebrum w LOC of 1-5 hrs 59 minutes, sequela.
    S06354ATraum hemor left cerebrum w LOC of 6 hours to 24 hours, init.
    S06354DTraum hemor left cerebrum w LOC of 6 hours to 24 hours, subs.
    S06354STraum hemor left cerebrum w LOC of 6-24 hrs, sequela.
    S06355ATraum hemor left cerebrum w LOC >24 hr w ret consc lev, init.
    S06355DTraum hemor left cerebrum w LOC >24 hr w ret consc lev, subs.
    S06355STraum hemor l cereb w LOC >24 hr w ret consc lev, sequela.
    Left cerebrum hemorrhage additional codesICD-10
    S06356ATraum hemor l cereb w LOC >24 hr w/o ret consc w surv, init.
    S06356DTraum hemor l cereb w LOC >24 hr w/o ret consc w surv, subs.
    S06356STraum hemor l cereb w LOC >24 hr w/o ret consc w surv, sequela.
    S06359ATraum hemor left cerebrum w LOC of unsp duration, init.
    S06359DTraum hemor left cerebrum w LOC of unsp duration, subs.
    S06359STraum hemor left cerebrum w LOC of unsp duration, sequela.
    Unspecified cerebrum hemorrhage codesICD-10
    S06360ATraum hemor cereb, w/o loss of consciousness, init.
    S06360DTraum hemor cereb, w/o loss of consciousness, subs.
    S06360STraum hemor cereb, w/o loss of consciousness, sequela.
    S06361ATraum hemor cereb, w LOC of 30 minutes or less, init.
    S06361DTraum hemor cereb, w LOC of 30 minutes or less, subs.
    S06361STraum hemor cereb, w LOC of 30 minutes or less, sequela.
    General cerebrum hemorrhage LOC categoriesICD-10
    S06362ATraum hemor cereb, w LOC of 31-59 min, init.
    S06362DTraum hemor cereb, w LOC of 31-59 min, subs.
    S06362STraum hemor cereb, w LOC of 31-59 min, sequela.
    S06363ATraum hemor cereb, w LOC of 1-5 hrs 59 minutes, init.
    S06363DTraum hemor cereb, w LOC of 1-5 hrs 59 minutes, subs.
    S06363STraum hemor cereb, w LOC of 1-5 hrs 59 minutes, sequela.
    S06364ATraum hemor cereb, w LOC of 6 hours to 24 hours, init.
    Further cerebrum hemorrhage codesICD-10
    S06364DTraum hemor cereb, w LOC of 6 hours to 24 hours, subs.
    S06364STraum hemor cereb, w LOC of 6 hours to 24 hours, sequela.
    S06365ATraum hemor cereb, w LOC >24 hr w ret consc lev, init.
    S06365DTraum hemor cereb, w LOC >24 hr w ret consc lev, subs.
    S06365STraum hemor cereb, w LOC >24 hr w ret consc lev, sequela.
    S06366ATraum hemor cereb, w LOC >24 hr w/o ret consc w surv, init.
    Cerebrum hemorrhage miscellaneous codesICD-10
    S06366DTraum hemor cereb, w LOC >24 hr w/o ret consc w surv, subs.
    S06366STraum hemor cereb, w LOC >24 hr w/o ret consc w surv, sequela.
    S06369ATraum hemor cereb, w LOC of unsp duration, init.
    S06369DTraum hemor cereb, w LOC of unsp duration, subs.
    S06369STraum hemor cereb, w LOC of unsp duration, sequela.
    S0636AATraum hemor cereb, with LOC status unknown, init.
    Cerebellum contusion/laceration/hemorrhage codesICD-10
    S06370AContus/lac/hem crblm w/o loss of consciousness, init.
    S06370DContus/lac/hem crblm w/o loss of consciousness, subs.
    S06370SContus/lac/hem crblm w/o loss of consciousness, sequela.
    S06371AContus/lac/hem crblm w LOC of 30 minutes or less, init.
    S06371DContus/lac/hem crblm w LOC of 30 minutes or less, subs.
    S06371SContus/lac/hem crblm w LOC of 30 minutes or less, sequela.
    Brainstem contusion/laceration/hemorrhage codesICD-10
    S06380AContus/lac/hem brainstem w/o loss of consciousness, init.
    S06380DContus/lac/hem brainstem w/o loss of consciousness, subs.
    S06380SContus/lac/hem brainstem w/o loss of consciousness, sequela.
    S06381AContus/lac/hem brainstem w LOC of 30 minutes or less, init.
    S06381DContus/lac/hem brainstem w LOC of 30 minutes or less, subs.
    S06381SContus/lac/hem brnst w LOC of 30 minutes or less, sequela.
    Epidural hemorrhage codesICD-10
    S064X0AEpidural hemorrhage w/o loss of consciousness, init encntr.
    S064X0DEpidural hemorrhage w/o loss of consciousness, subs encntr.
    S064X0SEpidural hemorrhage without loss of consciousness, sequela.
    S064X1AEpidural hemorrhage w LOC of 30 minutes or less, init.
    S064X1DEpidural hemorrhage w LOC of 30 minutes or less, subs.
    S064X1SEpidural hemorrhage w LOC of 30 minutes or less, sequela.
    Epidural hemorrhage LOC categoriesICD-10
    S064X2AEpidural hemorrhage w LOC of 31-59 min, init.
    S064X2DEpidural hemorrhage w LOC of 31-59 min, subs.
    S064X2SEpidural hemorrhage w LOC of 31-59 min, sequela.
    S064X3AEpidural hemorrhage w LOC of 1-5 hrs 59 min, init.
    S064X3DEpidural hemorrhage w LOC of 1-5 hrs 59 min, subs.
    S064X3SEpidural hemorrhage w LOC of 1-5 hrs 59 min, sequela.
    Epidural hemorrhage continuedICD-10
    S064X4AEpidural hemorrhage w LOC of 6 hours to 24 hours, init.
    S064X4DEpidural hemorrhage w LOC of 6 hours to 24 hours, subs.
    S064X4SEpidural hemorrhage w LOC of 6 hours to 24 hours, sequela.
    S064X5AEpidural hemorrhage w LOC >24 hr w ret consc lev, init.
    S064X5DEpidural hemorrhage w LOC >24 hr w ret consc lev, subs.
    S064X5SEpidural hemorrhage w LOC >24 hr w ret consc lev, sequela.
    Subdural hemorrhage codesICD-10
    S065X0ATraum subdr hem w/o loss of consciousness, init.
    S065X0DTraum subdr hem w/o loss of consciousness, subs.
    S065X0STraum subdr hem w/o loss of consciousness, sequela.
    S065X1ATraum subdr hem w LOC of 30 minutes or less, init.
    S065X1DTraum subdr hem w LOC of 30 minutes or less, subs.
    S065X1STraum subdr hem w LOC of 30 minutes or less, sequela.
    Subarachnoid hemorrhage codesICD-10
    S066X0ATraum subrac hem w/o loss of consciousness, init.
    S066X0DTraum subrac hem w/o loss of consciousness, subs.
    S066X0STraum subrac hem w/o loss of consciousness, sequela.
    S066X1ATraum subrac hem w LOC of 30 minutes or less, init.
    S066X1DTraum subrac hem w LOC of 30 minutes or less, subs.
    S066X1STraum subrac hem w LOC of 30 minutes or less, sequela.
    Intracranial carotid injury codesICD-10
    S06810AInjury of r int carotid, intcr w/o LOC, init.
    S06810DInjury of r int carotid, intcr w/o LOC, subs.
    S06810SInjury of r int carotid, intcr w/o LOC, sequela.
    S06811AInj r int carotid, intcr w LOC of 30 minutes or less, init.
    S06811DInj r int carotid, intcr w LOC of 30 minutes or less, subs.
    S06811SInj r int crtd, intcr w LOC of 30 minutes or less, sequela.
    Listed ICD-10-CM and S-series codes and symptom codesICD-10
    S06810SInjury of r int carotid, intcr w/o LOC, sequela
    S06811AInj r int carotid, intcr w LOC of 30 minutes or less, init
    S06811DInj r int carotid, intcr w LOC of 30 minutes or less, subs
    S06811SInj r int crtd, intcr w LOC of 30 minutes or less, sequela
    S06812AInjury of r int carotid, intcr w LOC of 31-59 min, init
    S06812DInjury of r int carotid, intcr w LOC of 31-59 min, subs
    S06812SInjury of r int carotid, intcr w LOC of 31-59 min, sequela
    S06813AInjury of r int carotid, intcr w LOC of 1-5 hrs 59 min, init
    S06813DInjury of r int carotid, intcr w LOC of 1-5 hrs 59 min, subs
    S06813SInj r int carotid, intcr w LOC of 1-5 hrs 59 min, sequela
    1–10 of 157
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    Prior Authorization, Documentation, and Denial Risk

    Prior Authorization

    Ensure admission meets medical necessity and documentation requirements

    Admission must meet the policy's medical necessity criteria and required documentation; inpatient stays are billed by revenue code rather than CPT/HCPCS.

    • Member must meet documentation requirements and have referral/diagnosis of ABI from PCP, neurologist, rehabilitation specialist, or recent inpatient stay.
    • Member must require at least two services (one intensive rehabilitative service plus at least one additional service).
    • Admission must meet all listed indications of need and documentation requirements.
    Prior Authorization

    Use listed ICD-10 codes on authorization requests and claims

    When requesting authorization or submitting claims, use the ICD-10 diagnosis codes listed in the policy segment that correspond to the member's ABI (examples include B2782, B2792, B375 and extensive S‑series codes).

    • Submit the ICD-10-CM codes shown in chunks 18–37 that map to the member's condition.

    Clinical Context and Scope

    Acquired brain injury (ABI) refers to non‑congenital, non‑degenerative injury to the brain occurring after birth and encompasses both traumatic and non‑traumatic causes (for example, stroke, anoxia, infection, tumor, toxic or metabolic encephalopathy). ABI may produce temporary or permanent impairments across cognitive, behavioral, motor, and communication domains. The policy covers subacute and chronic inpatient neurorehabilitation intended to improve functional independence and community reintegration in selected patients meeting the documented admission and continued‑stay criteria.

    Key Terms and Code Descriptors

    Acquired Brain Injury (ABI) — definition and core attributes
    DefinitionAn acquired brain injury (ABI) is an injury to the brain occurring after birth that is non-congenital and non-degenerative, causing temporary or permanent impairments (cognitive, behavioral, motor, communication)
    Etiology examplesIncludes traumatic (external blow/jolt) and non‑traumatic causes (stroke, anoxia, infection, tumor, metabolic/toxic exposures)
    Functional impactMay produce memory loss, personality change, impaired judgment, communication and mobility limitations, and psychosocial maladjustment
    Sequelae codes — use of I69 and related codes to denote long-term consequences
    Primary code familyICD-10-CM codes beginning with I69 denote sequelae (long-term consequences) of prior intracranial hemorrhage or cerebral infarction
    Examples of specific I69 codes

    Policy Dates and Approvals

    2025-08-01Effective DateLatest

    Policy AR.CP.MP.501 became effective on 2025-08-01.

    2025-06-16Last Revised

    Policy last revised on 2025-06-16 (recorded as 'New Policy' revision entry).

    2025-07-11Approval Date

    Policy approval recorded on 2025-07-11 following the 6/16/2025 revision.

    Policy Summary
    PayerQualChoice
    PolicyAcquired Brain Injury (Subacute and Chronic) Inpatient Neurorehabilitation
    Policy CodePolicy AR.CP.MP.501
    Change TypeNo material changes
    Effective DateAug 1, 2025
    Last ReviewJun 16, 2025
    Next Review DateJun 16, 2025
    Key ActionObtain prior authorization and submit appropriate ICD-10 diagnosis codes and required documentation demonstrating medical necessity (referral, evaluations, plan of care, and evidence of need for at least two services).
    SourceLink
    On This Page
    Medical Necessity — Admission, Continued Stay, and ExclusionsDiagnosis and Billing CodesPrior Authorization, Documentation, and Denial RiskClinical Context and ScopeKey Terms and Code DescriptorsPolicy Dates and Approvals

    Facility has up to 3 calendar days to stabilize any medical condition; inability to participate for 4 or more calendar days is an indication for discharge consideration.

    Medical stability: Member maintains medical stability as evidenced by absence of infection, vital signs within member baseline, and no new acute condition preventing participation in therapy (e.g., recent injury, CHF/COPD exacerbation, chest pain, DVT, need for IV hydration).

    If unstable, facility should stabilize within 3 calendar days or consider discharge.

    Documentation: Request for continued stay includes required documentation: progress notes for all prescribed therapies documenting participation and progress, updated plan of care with measurable goals and projected schedule, updated orders, interdisciplinary team review, education documentation, and discharge planning (including DME review).

    Discharge criteria are not met.

    Plateaued progress, return to baseline, or achievement of plan goals support discharge and denial of continued inpatient stay.

    Non-compliance due to refusal to participate or attend treatment sessions, or refusal to follow the plan of care.

    Repeated refusal that prevents therapeutic progress makes inpatient stay not medically necessary.

    Therapy intensity — minimum therapy intensity for continued stay
    Minimum daily intensityAt least 3 hours per day of rehabilitative treatment
    Weekly frequency5 days per week
    Continued stay requirementMember must continue participation in rehab at this intensity to meet continued-stay criteria
    Sequelae specification — use I69x series to document specific deficits
    Primary sequelae code seriesUse ICD-10-CM I69x series to document sequelae of prior intracranial hemorrhage or infarction
    Common sequelae capturedCognitive deficits, aphasia/dysphasia, dysarthria, memory and attention deficits
    Mapping guidanceAssign specific I69.x subclass codes for the neurologic deficit (e.g., I6901 for cognitive deficits following nontraumatic subarachnoid hemorrhage)
    Loss of consciousness duration markers — LOC categories used in codes
    LOC categories in S-codesCodes annotate loss-of-consciousness as: none; 30 minutes or less; 31–59 minutes; 1–5 hours 59 minutes; 6–24 hours; >24 hours; unspecified/status unknown
    Used across code groupsLOC markers appear in concussion (S06.0), cerebral edema (S06.1), diffuse/focal TBI (S06.2–S06.3) code descriptors
    Encounter modifiers pairedLOC duration markers are combined with encounter type (initial, subsequent, sequela) in S-series codes
    LOC duration categories — examples of LOC time ranges
    Example: short LOC30 minutes or less
    Example: moderate LOC31–59 minutes or 1–5 hours 59 minutes
    Example: prolonged LOC6–24 hours or greater than 24 hours
    Listed ICD-10-CM and S-series codes and symptom codes — duplicate referenceICD-10
    (see full list above)Comprehensive list of ICD-10-CM and S-series codes and symptom codes as provided in the policy (refer to the Listed ICD-10-CM and S-series codes group).
  1. Ensure codes describe the specific diagnosis (e.g., cytomegaloviral meningitis B2782).
    2. Note

    No prior authorization instructions in this code-list segment

    This content segment is a diagnostic code listing and does not itself specify prior authorization procedures or requirements.

    • The listed S‑codes and ICD descriptors are for diagnosis mapping; prior authorization rules are described elsewhere in the policy.
    • Do not infer prior authorization timing or submission method from this code list alone.
    Note

    Prior authorization not specified in this excerpt

    No explicit prior authorization requirements are specified in these extracted chunks; follow the Health Plan's administrative prior authorization policies when required.

    • Chunks in this excerpt list diagnosis descriptors but do not state specific prior authorization steps.
    • Confirm prior authorization requirements with the member's benefit plan or Health Plan administrative policies.
    Prior Authorization

    Obtain prior authorization per benefit plan when required

    This policy is a medical‑necessity guide to support coverage decisions; providers should obtain prior authorization when required by the member's benefit plan and Health Plan administrative policies.

    • Obtain prior authorization per the member's benefit contract and Health Plan administrative rules when applicable.
    • The clinical policy itself does not guarantee payment; follow plan-level preauthorization procedures.
    Step Therapy

    Document failed outpatient ABI therapy within last 30 days when used as indication

    If inability to maintain ADLs/IADLs at home is cited, document failure of outpatient ABI therapy within the last 30 days; admission indications require failed or no improvement from outpatient therapy when relevant.

    • Document outpatient therapy attempts and lack of improvement within the previous 30 days if used to justify inpatient admission.
    • Use this documentation to support the indication that the member cannot maintain ADLs/IADLs at home.
    Note

    Confirm specific S‑code mappings when applicable

    (See referenced code lists for action details.)

    Documentation Required

    Map clinical findings to S‑series descriptors on the record

    (See referenced code lists for action details.)

    Documentation Required

    Use provided ICD‑10 I69 series descriptors to specify sequelae

    (See referenced code lists for action details.)

    Documentation Required

    Ensure required clinical evaluations and plan of care are on file

    (Placeholder — follow documentation sections for required elements.)

    Documentation Required

    Document clinical evaluations, diagnoses, date of onset, and comprehensive plan of care

    Progress notes and therapy documentation must include clinical evaluations, diagnoses and date of onset, diagnostic evaluations, prior therapy results, potential for improvement, and current/prior functional levels to support admission and continued stay.

    • Evaluation relevant to each therapy discipline for which services will be rendered.
    • Plan of care with specific, measurable goals; projected schedule with frequency/duration; personnel providing services; caregiver education plan.
    • Progress notes documenting participation and measurable progress for continued stay; updates to orders and discharge planning.
    Documentation Required

    Submit supporting ICD‑10 diagnosis codes that match the member's ABI

    Providers must submit appropriate ICD‑10 diagnosis codes from the policy's lists that correspond to the member's acquired brain injury to support inpatient neurorehabilitation requests and claims.

    • Include diagnosis codes that map to the member's clinical presentation (e.g., infectious meningitis codes in chunk 18; sequelae codes in chunk 37).
    • Ensure submitted codes are among those listed in the policy to support coverage.
    Billing Rule

    Document and claim using the specific S‑series codes listed in the policy

    Use the specific S‑series ICD‑10‑CM codes listed (S0211…, S06333S, S06334A, etc.) in documentation and claims to reflect fracture types, TBI subtype, LOC duration, encounter type and sequela as applicable.

    • Select S‑codes that specify side, encounter status (initial/subsequent/sequela), and LOC duration when applicable (e.g., S06333S = contusion/laceration with LOC 1–5 hrs 59 min, sequela).
    • Include S‑code descriptors on the medical record and claims to map to the member's condition.
    Billing Rule

    Document S‑series diagnosis descriptors on claims to match clinical presentation

    Include the S‑series diagnosis descriptors (e.g., S06..., S06333S) on claims and map them to the member's clinical condition; failure to document appropriate S‑codes may lead to claim processing issues.

    • Map clinical diagnosis (LOC category, side, encounter type) to the exact S‑code descriptor before billing.
    • Document the S‑code in the medical record to support the billed diagnosis on the claim.
    Documentation Required

    Adhere to coverage documents and regulatory/compliance requirements

    Providers must adhere to the member's coverage documents, applicable state/federal requirements, and Medicare NCDs/LCDs as applicable; documentation should support medical necessity per this clinical policy and related coverage documents.

    • Follow benefit contract terms, state/federal laws, and Health Plan administrative policies.
    • Ensure documentation supports medical necessity and aligns with applicable NCDs/LCDs when relevant.
    Denial Risk

    Risk of denial if inpatient level no longer appropriate or documentation insufficient

    Denial may be recommended if the inpatient level of care is no longer clinically appropriate, therapy documentation does not support skilled inpatient services, or the member meets any not‑medically‑necessary conditions (e.g., medically unstable, requires ventilator, custodial care, independent for self‑care, plateaued progress).

    • A review may be performed and denial recommended if therapy documentation fails to support functional benefit at an inpatient level.
    • Not‑medically‑necessary conditions include need for ventilator, IV nutrition, custodial care, inability to participate in 3 hrs/day 5 days/week, independence in ADLs, plateaued progress, or achieved goals.
    Denial Risk

    Diagnosis codes not listed in policy may trigger claim denial

    Claims may be denied if submitted diagnosis codes are not among the covered or allowed diagnoses listed in the policy.

    • Verify that the principal and supporting diagnosis codes are included in the policy's listed ICD‑10 codes before submission.
    • Incorrect or unsupported diagnosis coding may result in claim denial.
    Note

    Coding list is informational — miscoding increases denial risk

    The code lists in these chunks are diagnostic descriptors; miscoding or use of non‑listed descriptors could trigger coverage or denial actions by claims systems if diagnoses do not match policy lists.

    • Ensure the code descriptor (e.g., specific fracture or TBI LOC category) matches the clinical documentation.
    • Coding errors in S‑series or I‑series descriptors increase the risk of administrative denial or requests for additional information.
    Denial Risk

    Denial risk from coding mismatches or unsupported descriptors

    If diagnosis descriptors are mis‑coded or not supported by documentation, claims or authorizations could be denied; carefully map clinical findings to the listed code descriptors.

    • Confirm LOC duration, encounter type, and sequela status before assigning S‑series or other ICD‑10 codes.
    • Maintain medical record evidence that supports chosen diagnosis codes.
    Denial Risk

    Administrative coverage provisions and benefit limits can trigger denial

    Coverage decisions are subject to terms, exclusions and limitations of the member's coverage documents and to state and federal requirements; failure to follow these administrative provisions may result in denial.

    • State Medicaid provisions take precedence when they conflict with this clinical policy.
    • The policy is a guide; confirm coverage limitations and exclusions in the member's benefits before submission.
    I6901 (cognitive deficits following nontraumatic subarachnoid hemorrhage); I69120 (aphasia following nontraumatic intracerebral hemorrhage); I69122 (dysarthria)
    Use caseApply I69.x codes to document persistent cognitive, speech, motor, or functional deficits resulting from prior brain injury
    S06-series (examples in text) — concussion and TBI descriptors with modifiers
    S06-series scopeS06 codes describe concussion, traumatic cerebral edema, diffuse and focal traumatic brain injury with modifiers for LOC duration and encounter type
    Concussion examplesS060X0A (concussion without LOC, initial); S060X1A (concussion w LOC ≤30 min, initial); S060X4A (concussion w LOC 6–24 hrs, initial)
    Cerebral edema examplesS061X0A (traumatic cerebral edema w/o LOC, initial); S061X3A (w LOC 1–5 hrs 59 min, initial)
    LOC descriptors — loss-of-consciousness categories annotated in code descriptions
    LOC annotation purposeLOC descriptors (e.g., 'LOC of 1–5 hrs 59 min', 'LOC >24 hr w ret consc lev') are used in S06x/S063xx code descriptions to subtype severity and encounter
    Status qualifiersCodes include entries for unspecified duration and for LOC status unknown to capture incomplete histories
    Sequalae pairingLOC descriptors appear for initial, subsequent, and sequela encounters (e.g., S06333S = sequela with LOC 1–5 hrs 59 min)
    Posttraumatic conditions and deficits — examples of common posttraumatic functional deficits
    Common posttraumatic deficitsAttention and concentration deficits; cognitive communication deficits; visuospatial deficits; psychomotor deficits; frontal/executive dysfunction
    Other functional examplesPosttraumatic headache (chronic/intractable), dizziness, anosmia (loss of smell), slurred speech, posttraumatic seizures
    Coding referencesUse symptom and sign codes (e.g., R41.840 attention deficit, R41.841 cognitive communication deficit, G44.321 chronic posttraumatic headache) to document specific deficits