ModifiedUnitedHealthcarePolicy CS020TN.T

Cognitive Rehabilitation and Coma Stimulation (for Tennessee Only)

Outpatient cognitive rehabilitation and coma stimulation services for Tennessee Medicaid and CoverKids members; defines coverage stance and clinical context for these services.

Policy Summary

PayerUnitedHealthcare

PolicyCognitive Rehabilitation and Coma Stimulation (for Tennessee Only)

Policy CodePolicy CS020TN.T

Change TypeScope and definitional updates (DOC added)clarifies coma stimulation stance

Effective DateDec 1, 2025

Next Review DateN/A

Key ActionReference InterQual outpatient rehabilitation criteria for medical necessity when requesting coverage for outpatient cognitive rehabilitation.

SourceLink

POLICY UPDATE CHANGES

Replaced language stating coma stimulation is not medically necessary for 'any indication, including individuals who are comatose, in a vegetative or minimally conscious state' with language stating coma stimulation is unproven and not medically necessary for any 'Disorder of Consciousness (DOC)'.

Added a definition of 'Disorder of Consciousness (DOC)'.

Removed definitions for Coma/Persistent Vegetative State and Minimally Conscious State.

Updated Description of Services, Clinical Evidence, and References sections to reflect the most current information.

Outpatient onlysetting

Not medically necessarycoma stimulation stance

InterQual

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medical necessity source

97129/97130/S9056codes listed

1previous version archived

Coverage Criteria

Cognitive Rehabilitation (Outpatient)

Covered when ALL of the following are met per InterQual outpatient rehabilitation criteria

InterQual-based CR coverage: Outpatient Cognitive Rehabilitation is proven and medically necessary under certain circumstances as defined by InterQual LOC: Outpatient Rehabilitation & Chiropractic (refer to InterQual for the specific clinical criteria).refer to InterQual

Policy directs providers to InterQual criteria for exact medical necessity rules

Coma Stimulation (Not Medically Necessary)

Coma Stimulation (multimodal sensory stimulation/ coma arousal programs) is considered unproven and not medically necessary due to insufficient evidence of efficacy for any Disorder of Consciousness (DOC).N/A

Policy cites limited and heterogeneous trials and systematic reviews as rationale; claims for coma stimulation may be denied as not medically necessary.

This policy applies to outpatient Cognitive Rehabilitation services only. Inpatient rehabilitation, acute hospital, skilled nursing facility, or other non‑outpatient settings are not addressed by this policy; providers should refer to the applicable benefit plan and setting‑specific guidance for services delivered outside the outpatient setting.

Coma stimulation (also referred to as coma arousal, coma responsiveness, multisensory stimulation, and coma care therapy/programs) involves multimodal sensory interventions intended to promote arousal or recovery in individuals with impaired consciousness. The literature includes small and heterogeneous trials (e.g., sensory stimulation, rTMS, tDCS, VNS, tilting) with variable outcome measures such as the Coma Recovery Scale–Revised (CRS‑R) and Glasgow Coma Scale (GCS); overall, controlled trials are limited and do not consistently demonstrate a reproducible, positive impact on meaningful health outcomes.

Because available studies are limited in size, methodology, and consistency of results, coma stimulation is considered unproven. The policy’s rationale cites systematic reviews and controlled trial limitations showing inconsistent evidence of benefit across interventions and outcomes, and therefore concludes that coma stimulation lacks sufficient evidence to meet medical necessity standards.

Accordingly, coma stimulation is designated not medically necessary for the treatment of impaired consciousness. This determination reflects the policy conclusion that multimodal sensory stimulation programs have insufficient, inconsistent evidence of efficacy and do not meet UnitedHealthcare’s criteria for covered outpatient services.

Coding

Covered CPT Codes (referenced for CR services)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

HCPCS Codes (coma stimulation)HCPCSNot Covered

S9056

Coma stimulation per diem

Provider Actions and Billing Guidance

Prior Authorization

Prior Authorization and Utilization Review

Prior authorization and utilization review: Check member-specific plan benefits and any federal, state or contractual requirements before delivering outpatient cognitive rehabilitation services. UnitedHealthcare may require prior authorization or utilization review for outpatient CR and may use third-party tools such as InterQual® to determine medical necessity. Verify coverage and obtain any required prior authorization before scheduling services.

Verify member-specific benefits and plan governing requirements (federal, state, contractual) before treatment
Obtain prior authorization when required by the member's plan
UnitedHealthcare may apply InterQual® criteria for utilization review

Denial Risk

Denial Risk — Coma Stimulation

Denial risk for coma stimulation: Coma stimulation (also known as coma arousal, coma responsiveness, multisensory stimulation, coma care therapy/programs) is considered unproven and not medically necessary for any Disorder of Consciousness (DOC). Claims submitted for coma stimulation (for any DOC) may be denied as not medically necessary.

Definitions

Cognitive Rehabilitation (CR) definition — multidisciplinary outpatient program

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.

GoalTo maximize functional independence with minimal interference from cognitive limitations.

ApproachIncludes restorative tasks to reinforce previously learned behaviors and compensatory strategies to establish new mechanisms for impaired neurologic systems.

Coma Stimulation definition — multimodal sensory stimulation to improve arousal

Term

Background and Evidence

Cognitive rehabilitation (CR) is a multidisciplinary, outpatient program aimed at restoring or compensating for deficits across cognitive domains—such as memory, attention, executive function, and language—with the overall goal of maximizing functional independence and participation in daily activities. When indicated, CR may use restorative approaches (retraining impaired processes) or compensatory strategies (teaching skills or using aids to offset deficits). Coverage for outpatient CR under this policy is contingent on meeting established medical necessity criteria as defined by InterQual® LOC: Outpatient Rehabilitation & Chiropractic; providers must document the InterQual criteria referenced to support coverage decisions.

Revision History

2025-12-01revisionLatest

Title changed from 'Cognitive Rehabilitation (for Tennessee Only)'; replaced prior wording to clarify that coma stimulation is unproven and not medically necessary for any 'Disorder of Consciousness (DOC)'; added definition of 'Disorder of Consciousness (DOC)'; removed definition for Coma/Persistent Vegetative State (and Minimally Conscious State); supporting information updated and previous policy version archived.

Policy Summary

PayerUnitedHealthcare

PolicyCognitive Rehabilitation and Coma Stimulation (for Tennessee Only)

Policy CodePolicy CS020TN.T

Change TypeScope and definitional updates (DOC added)clarifies coma stimulation stance

Effective DateDec 1, 2025

Next Review DateN/A

Key ActionReference InterQual outpatient rehabilitation criteria for medical necessity when requesting coverage for outpatient cognitive rehabilitation.

SourceLink

On This Page

S9056 (Coma stimulation per diem) may be considered not medically necessary and denied
Services described as coma stimulation for any DOC are at high risk for denial

Documentation Required

Documentation to Support Cognitive Rehabilitation

Documentation to support Cognitive Rehabilitation (CR): Maintain documentation consistent with InterQual® Outpatient Rehabilitation & Chiropractic levels of care and medical necessity guidance. Clinical records should clearly describe the cognitive deficits, objective assessment findings, treatment goals, skilled therapeutic interventions, progress toward goals, and time spent (for time-based CPT codes).

Document diagnosis, baseline cognitive impairment, and functional impact
Record objective assessments and measurable treatment goals
Document skilled interventions, date/time and total time in direct one-on-one therapy (for CPT 97129/97130)
Include progress notes showing response to therapy and justification for continued skilled services

Note

Benefit Verification and Governing Requirements

Benefit verification and governing requirements: Always verify the member's benefit plan to determine covered services, prior authorization requirements, and any applicable limits. Federal, state, or contractual plan terms may override the standard policy; in case of conflict, the governing requirements prevail. UnitedHealthcare reserves the right to modify policies and may use third-party criteria in administration.

Benefit coverage is determined by the member-specific benefit plan document
Check for state/federal mandates or contractual provisions that may require coverage
In the event of conflict, federal/state/contractual requirements govern

Billing Rule

Provider Action Summary

Provider action reminder: Prior authorization, accurate coding, and thorough documentation are required to reduce denial risk. Ensure services billed for cognitive rehabilitation use appropriate CPT codes (e.g., 97129, 97130) with time documented, and avoid billing coma stimulation (S9056) as a medically necessary CR service for DOC.

Use CPT 97129 (initial 15 minutes) and 97130 (each additional 15 minutes) for skilled cognitive rehabilitation when medically necessary
Do not bill coma stimulation as medically necessary for DOC; S9056 may be denied
Obtain prior authorization if required and retain complete documentation to support medical necessity

DefinitionThe use of multimodal sensory stimulation in an attempt to speed up the process of recovery from coma or improve arousal level.

Also known asComa arousal, coma responsiveness, multisensory stimulation, coma care therapy/programs.

Evidence summaryControlled trials are limited and evidence is insufficient to demonstrate efficacy for disorders of consciousness.

Disorder of Consciousness (DOC) — state of prolonged altered consciousness definition

TermDisorder of Consciousness (DOC)

DefinitionA state of prolonged altered consciousness that can be categorized into coma, vegetative state, or minimally conscious state based on neurobehavioral function.

ContextUsed to describe prolonged impaired consciousness assessed by neurobehavioral criteria (Eapen et al., 2017).

Policy-added Disorder of Consciousness (DOC) definition replacement text

Policy changeReplaced prior language referencing specific states (coma, vegetative state, minimally conscious state) with the broader term 'Disorder of Consciousness (DOC)'.

New definition added'Disorder of Consciousness (DOC)' definition was added to the policy and previous specific-state definitions were removed.

Coverage implicationComa Stimulation is clarified as unproven and not medically necessary for any Disorder of Consciousness (DOC).