ModifiedUnitedHealthcarePolicy CS020.R

Cognitive Rehabilitation

Outpatient cognitive rehabilitation services for individuals with cognitive deficits; medical necessity references InterQual LOC: Outpatient Rehabilitation & Chiropractic; coma stimulation is excluded as not medically necessary; affects providers and benefit determinations.

Policy Summary

PayerUnitedHealthcare

PolicyCognitive Rehabilitation

Policy CodePolicy CS020.R

Change TypeClarified scoperevised medical necessity languagestate applicability updated

Effective DateDec 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization when billing outpatient cognitive rehabilitation services and document clinical information aligning with InterQual criteria.

SourceLink

POLICY UPDATE CHANGES

Policy clarified to apply to outpatient Cognitive Rehabilitation services only.

Replaced language that CR is proven and medically necessary for TBI or stroke with 'Cognitive Rehabilitation (CR) is proven and medically necessary under certain circumstances'.

Policy now indicates it does not apply to the state of Idaho.

Removed definition of 'Executive Functions'.

Outpatient onlyScope

Not medically necessaryComa Stimulation stance

InterQual referencedCriteria source

97129/97130/S9056Example codes

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Coverage Criteria

Medical necessity (InterQual referenced)

Covered when ALL of the following are met per InterQual LOC: Outpatient Rehabilitation & Chiropractic

InterQual-based medical necessity: Outpatient cognitive rehabilitation covered when clinical criteria in InterQual LOC: Outpatient Rehabilitation & Chiropractic are satisfied.refer to InterQual

Policy directs users to InterQual for detailed clinical coverage criteria

Coma Stimulation (also called coma arousal, multisensory stimulation, or coma care programs) is considered unproven and is not medically necessary for any indication, including individuals who are comatose, in a Vegetative State, or in a Minimally Conscious State.

This medical policy does not apply to the state of Idaho; providers should follow the applicable state- and plan-specific rules for members in Idaho.

Coma Stimulation is considered not medically necessary due to insufficient evidence of efficacy. There are no established protocols or definitive patient selection criteria to support its routine use to promote awakening or improve arousal after brain injury.

The American Academy of Neurology (AAN) practice guideline (2018, reaffirmed 2021) does not address stimulation as an established treatment for prolonged disorders of consciousness and recommends counseling families about the limitations of the existing evidence; there are no established therapies for children with prolonged disorders of consciousness.

Coding

Covered CPT Codes (referenced)CPT

97129

Therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes.

97130

Coma Stimulation codeHCPCSNot Covered

S9056

Coma stimulation per diem

Provider Actions and Billing Guidance

Prior Authorization

Prior Authorization Depends on Plan

Prior authorization requirements vary by UnitedHealthcare plan and contract. Providers should check member-specific benefit documents or contact UnitedHealthcare to determine if prior authorization is required for outpatient Cognitive Rehabilitation services and, if required, secure authorization before rendering services.

Prior authorization may be required depending on the member's contract
InterQual may be used by UnitedHealthcare to assist with medical necessity determinations

Billing Rule

Setting and State Applicability

This policy applies to outpatient Cognitive Rehabilitation services only. Claims for services provided in settings outside the outpatient setting or for states specifically excluded from this policy (for example, Idaho per Policy History) may be subject to denial or governed by alternate policy language. Verify the member's state and service setting before submitting claims.

Background

Cognitive impairment can affect memory, attention, executive function, language, and visuoperceptual abilities. Cognitive Rehabilitation (CR) is a multidisciplinary program using restorative and compensatory approaches to improve or compensate for impaired cognitive skills and maximize functional independence. CR is proven and may be medically necessary under certain circumstances for outpatient services when clinical criteria are met (see InterQual® LOC: Outpatient Rehabilitation & Chiropractic).

Coma Stimulation is a distinct intervention that uses multimodal sensory input to attempt to accelerate recovery of consciousness; unlike CR, it lacks established protocols, patient selection criteria, and sufficient evidence of benefit.

Definitions

Definition — Cognitive Rehabilitation (CR)

TermCognitive Rehabilitation (CR)

DefinitionA multidisciplinary treatment program designed to improve cognitive function and retrain an individual's ability to think, use judgment, and make decisions; focuses on deficits in memory, attention, perception, visual processing, language, reasoning, learning, planning, judgment, and problem-solving.

GoalMaximize functional independence with minimal interference from cognitive limitations through restorative tasks and compensatory mechanisms.

Definition — Coma Stimulation (multimodal sensory stimulation)

TermComa Stimulation (multimodal sensory stimulation)

DefinitionThe use of multimodal sensory stimulation in an attempt to speed recovery from coma or to improve arousal level; no established protocols or definitive patient selection criteria are described in the policy.

Revision History

2025-06-01material_updateLatest

Policy updated to add that it does not apply to the state of Idaho.

2024-12-01material_update

Clarified that the policy applies to outpatient Cognitive Rehabilitation services only and revised language to state that Cognitive Rehabilitation (CR) is proven and medically necessary under certain circumstances rather than universally for TBI or stroke; definitions and supporting sections updated and prior policy version archived.

Policy Summary

PayerUnitedHealthcare

PolicyCognitive Rehabilitation

Policy CodePolicy CS020.R

Change TypeClarified scoperevised medical necessity languagestate applicability updated

Effective DateDec 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization when billing outpatient cognitive rehabilitation services and document clinical information aligning with InterQual criteria.

SourceLink

On This Page

Outpatient setting only — services billed for non-outpatient settings may be denied
Policy exclusions by state (e.g., Idaho) supersede this guidance; check state-specific rules

Documentation Required

Documentation and Plan Contract Precedence

Benefit determinations reference third-party criteria (e.g., InterQual LOC: Outpatient Rehabilitation & Chiropractic) and must align with the member's federal, state, or contractual plan terms. When there is a conflict between this Medical Policy and the member's benefit plan or applicable law, the federal, state, or contractual requirements govern. Providers should include relevant clinical documentation to support medical necessity determinations.

Use InterQual criteria as the referenced clinical standard for medical necessity decisions
When plan language conflicts with this policy, plan/federal/state terms take precedence
Document clinical information and rationale supporting medical necessity when requesting authorization

Policy stanceConsidered unproven and not medically necessary for any indication per policy exclusions.

Definition — Coma/Persistent Vegetative State (description)

TermComa / Persistent Vegetative State

DescriptionA long, deep state of unconsciousness in which people are alive but unable to move or respond to their surroundings.

Policy noteDefinition updated in the policy's revision history (12/01/2024).

Definition — Minimally Conscious State (description)

TermMinimally Conscious State

DescriptionA condition after severe brain injury in which the person retains limited awareness of self and environment, is awake, and is occasionally able to communicate or perform simple voluntary activities demonstrating engagement with surroundings.

Clinical implicationRepresents residual cognitive function distinct from coma or vegetative state.

Definition — Coma/Persistent Vegetative State (updated wording referenced in policy)

Updated termComa/Persistent Vegetative State (policy update)

Updated wordingPolicy revision 12/01/2024 indicates the definition of Coma/Persistent Vegetative State was updated in the policy's definitions section.

ReferenceSee Definitions section for revised language describing a long, deep state of unconsciousness where individuals are alive but unable to move or respond to surroundings.

AAN position — Stimulation for disorders of consciousness not established; no protocols.

Source (AAN)2018 AAN practice guideline (reaffirmed 2021) does not address stimulation as a treatment for prolonged disorders of consciousness and notes there are no established therapies for children with prolonged disorders of consciousness.

GuidanceFamilies should be counseled regarding limitations of existing evidence for interventions that lack support.

Policy implicationUnitedHealthcare cites AAN guidance to support that stimulation for disorders of consciousness is not an established therapy and lacks standardized protocols.