CurrentUnitedHealthcarePolicy CSO2OID.B

Cognitive Rehabilitation (for Idaho Only)

UnitedHealthcare medical policy governing outpatient cognitive rehabilitation services for members in Idaho, including Idaho Medicaid Plus plans. State-specific medical necessity criteria are delegated to the Idaho Medicaid Provider Handbook; InterQual LOC is referenced for visit number/frequency.

Policy Summary

PayerUnitedHealthcare

PolicyCognitive Rehabilitation (for Idaho Only)

Policy CodePolicy CSO2OID.B

Change TypeState-specific criteria added; InterQual referenced for visit frequency

Effective DateAug 1, 2025

Next Review Date

Key ActionProviders must use the Idaho Medicaid Provider Handbook, Therapy Services, Section 5.13 for clinical medical necessity criteria when requesting or documenting outpatient cognitive rehabilitation for Idaho members.

POLICY UPDATE CHANGES

Coverage Rationale State-Specific Criteria: Added instruction to refer to the Idaho Medicaid Provider Handbook; Therapy Services, Chapter 5.13: Cognitive Rehabilitation (OT/SLP) for medical necessity clinical coverage criteria.

Non State-Specific Criteria: Replaced coverage statement to refer to InterQual LOC for number and frequency of therapy visits.

Archived previous policy version CSO2OID.A

Supporting Information: Updated References section to reflect the most current information.

1State-specific reference required

1Not medically necessary: Coma Stimulation

Coverage Summary

Overview: This UnitedHealthcare policy (Policy Number CSO2OID.B) governs outpatient Cognitive Rehabilitation (CR) services for members in Idaho, including Idaho Medicaid Plus plans. The policy stance is mixed: CR is recognized as a multidisciplinary therapy with evidence of benefit in some conditions but with limitations in study quality and heterogeneity. For medical necessity determinations in Idaho, the policy defers to the Idaho Medicaid Provider Handbook (Therapy Services, Chapter 5.13) and uses InterQual LOC for visit number and frequency. Effective date: 2025-08-01.

Policy Identifiers

ScopeUnitedHealthcare medical policy governing outpatient cognitive rehabilitation services for members in Idaho, including Idaho Medicaid Plus plans; state-specific medical necessity criteria delegated to the Idaho Medicaid Provider Handbook (Therapy Services, Chapter 5.13)

Policy numberCSO2OID.B

Effective dateAugust 1, 2025

StatusCURRENT

Coverage stancemixed (outpatient cognitive rehabilitation covered per state-specific criteria; Coma Stimulation designated unproven/not medically necessary)

Medical Necessity Criteria

State-Specific Criteria

Medical necessity clinical coverage criteria are determined by the Idaho Medicaid Provider Handbook:

Refer to Idaho Medicaid Provider Handbook, Therapy Services, Chapter 5.13: Cognitive Rehabilitation (OT/SLP) for medical necessity clinical coverage criteria for Cognitive Rehabilitation

Non State-Specific Criteria (Number and Frequency)

Number and frequency of therapy visits:

Refer to the InterQual LOC: Outpatient Rehabilitation & Chiropractic for number and frequency of therapy visits

Unproven / Not Medically Necessary

Services determined unproven/not medically necessary:

Coma Stimulation (also known as Coma arousal; Coma responsiveness, multisensory stimulation; and Coma care therapy/programs) is unproven and not medically necessary due to insufficient evidence of efficacy for any indication, including individuals who are comatose, in a Vegetative or Minimally Conscious State

Provider Actions & Billing Impact

Documentation Required

Follow Idaho-specific medical necessity criteria

Providers must use the Idaho Medicaid Provider Handbook, Therapy Services, Section 5.13 for clinical medical necessity criteria when requesting or documenting outpatient cognitive rehabilitation for Idaho members.

See Idaho Medicaid Provider Handbook; Therapy Services, Section 5.13: Cognitive Rehabilitation (OT/SLP).

Documentation Required

Use InterQual for visit frequency

Number and frequency of therapy visits should be determined using InterQual LOC: Outpatient Rehabilitation & Chiropractic; document adherence to InterQual criteria when requesting levels of service.

InterQual LOC: Outpatient Rehabilitation & Chiropractic (use for visit number and frequency).

Coding

Cognitive therapeutic CPT codes (reference)CPT

97129	Therapeutic interventions that focus on cognitive function, direct (one-on-one) patient contact; initial 15 minutes.
97130	Therapeutic interventions that focus on cognitive function, direct (one-on-one) patient contact; each additional 15 minutes (List separately in addition to code for primary procedure).

Coma stimulation per diem (reference)HCPCSNot Covered

S9056

Coma stimulation per diem

Background & Evidence

Background: Cognitive Rehabilitation (CR) is defined as a multidisciplinary outpatient program using restorative and compensatory strategies to improve cognitive domains (memory, attention, executive function) and maximize functional independence. Virtual reality (VR)-based CR is an emerging, small but growing modality with potential advantages (immersive, engaging, gamified) but currently lacks standardized device protocols or definitive patient selection criteria.

Coma stimulation (also termed coma arousal, multisensory stimulation, coma care programs) involves multimodal sensory input intended to speed recovery from coma or improve arousal. The policy states there are no established protocols or definitive patient selection criteria, and evidence is inconsistent; as a result coma stimulation is designated unproven and not medically necessary.

Key evidence and policy interpretation:

• Braga et al. (2024): A prospective observational study of 208 long-COVID patients in a multidisciplinary program reported that ~70% of participants reported subjective cognitive improvement and some objective gains; the study is limited by its observational design and lack of pre-COVID baseline, so results are suggestive but not definitive.

• VR-based CR: Systematic reviews of small RCTs (group sizes often 6–34) report improvements in visual working memory and executive function after fully immersive VR training, but studies are heterogeneous with 'some concerns' or 'high' risk of bias; the evidence is preliminary and larger standardized trials are needed.

• CR across disorders: Multiple small RCTs and systematic reviews in conditions such as schizophrenia, Parkinson disease, MCI, and dementia report some cognitive gains and potential neural/functional changes, but limitations (small samples, heterogeneity, short follow-up) prevent firm conclusions.

• Coma stimulation: Systematic reviews report mixed findings — some reviews suggest possible short-term arousal benefits with heterogenous protocols and small studies, while guideline statements highlight lack of established therapies; the policy concludes the evidence is insufficient and classifies coma stimulation as unproven/not medically necessary.

Revision History

08/01/2025material_changeLatest

Coverage Rationale State-Specific Criteria: Added instruction to refer to the Idaho Medicaid Provider Handbook, Therapy Services, Chapter 5.13: Cognitive Rehabilitation (OT/SLP) for medical necessity clinical coverage criteria for Cognitive Rehabilitation.

08/01/2025material_changeLatest

Non State-Specific Criteria revised to reference InterQual LOC for number and frequency of therapy visits (replaced prior instruction referencing InterQual for medical necessity clinical coverage criteria).