ModifiedUnitedHealthcarePolicy CS020NM.C

Cognitive Rehabilitation and Coma Stimulation (for New Mexico Only)

Outpatient cognitive rehabilitation and coma stimulation services in New Mexico; defines coverage stance and clinical context for providers and payers in that state.

Policy Summary

PayerUnitedHealthcare

PolicyCognitive Rehabilitation and Coma Stimulation (for New Mexico Only)

Policy CodePolicy CS020NM.C

Change TypeDefinitions and title updatedDOC addedprior definitions removed

Effective DateDec 1, 2025

Next Review DateN/A

Key ActionUse InterQual LOC: Outpatient Rehabilitation & Chiropractic to establish medical necessity for outpatient cognitive rehabilitation and verify member benefits prior to authorization.

SourceLink

POLICY UPDATE CHANGES

Replaced language that coma stimulation is unproven and not medically necessary for any indication including comatose, vegetative or minimally conscious states with language that coma stimulation is unproven and not medically necessary for any Disorder of Consciousness (DOC).

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

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

Updated Description of Services, Clinical Evidence, and References to reflect current information; archived previous policy version CS020NM.B.

New MexicoGeographic applicability

97129, 97130Cognitive rehab CPTs

S9056Coma stimulation code

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Coma stimulation = NMN

Added DOCDefinition change

Coverage Criteria and Policy Stance

Cognitive Rehabilitation (Outpatient) - Coverage Criteria

Covered when criteria in the referenced InterQual LOC are met.

InterQual-based medical necessity: Outpatient Cognitive Rehabilitation is considered proven and medically necessary under certain circumstances; medical necessity clinical coverage criteria are governed by InterQual LOC: Outpatient Rehabilitation & Chiropractic (refer to InterQual for specific criteria).

Provider must use InterQual criteria to establish medical necessity; this policy applies to outpatient CR only.

Coma Stimulation - Not Medically Necessary

Not covered due to insufficient evidence.

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

Systematic reviews and trials are limited, heterogeneous, and lack established, reproducible protocols; some small studies report short-term improvements but overall evidence is insufficient to support coverage.

Stance on coma stimulation and FDA note

Policy statements and supporting notes present in this section:

Coma stimulation (coma arousal/multisensory stimulation): Coma Stimulation is considered unproven and not medically necessary for any Disorder of Consciousness (DOC).

Policy language was revised to replace prior references to comatose, vegetative, or minimally conscious states with the term 'Disorder of Consciousness (DOC)'.

Cognitive rehabilitation general note: Cognitive rehabilitation is therapy and is not subject to FDA regulation; FDA approval alone is not a basis for coverage.

Informational only.

This policy applies to outpatient Cognitive Rehabilitation (CR) services only. Medical necessity for outpatient CR is determined using the referenced InterQual® LOC: Outpatient Rehabilitation & Chiropractic; providers should refer to InterQual for the specific clinical coverage criteria that establish when outpatient CR is considered proven and medically necessary.

Coma stimulation — also referred to as coma arousal, coma responsiveness, multisensory stimulation, or coma care therapy/programs — is addressed separately in this policy. The revised policy language (effective with the update documented in the policy history) states that coma stimulation is not medically necessary for specified clinical indications; see the following paragraphs for the policy rationale and scope of that determination.

Coma stimulation involves multimodal sensory input intended to improve arousal in patients with impaired consciousness. Current evidence is limited, heterogeneous, and does not provide consistent, high-quality proof of efficacy. As a result, coma stimulation is considered unproven for improving outcomes in disorders of consciousness.

Per this policy, coma stimulation is unproven and not medically necessary for any Disorder of Consciousness (DOC). The policy revision replaced earlier language that listed specific states (coma, vegetative, minimally conscious) with the single term DOC and explicitly designates coma stimulation as not medically necessary for DOC indications.

Coding and Billing

Covered CPT Codes (cognitive rehabilitation) - listed for referenceCPTCovered

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)HCPCS

S9056

Coma stimulation per diem

Duration of injury subgroup analysis — outcomes for injuries >3 months

Subgroup analyzedDuration of injury > 3 months

FindingOverall effect of tDCS, rTMS, sensory stimulation, and VNS showed improvement in injuries over 3 months

Outcome measuresComa Recovery Scale-Revised (CRS-R) primary; Glasgow Coma Scale (GCS) secondary

Study summaryKumar et al. (2024) systematic review/meta-analysis included 31 intervention studies (574 individuals) and 19 controlled studies (417 individuals)

Provider Responsibilities and Prior Authorization

Prior Authorization

Use InterQual LOC to determine necessity

Refer to InterQual® LOC: Outpatient Rehabilitation & Chiropractic to determine medical necessity for outpatient Cognitive Rehabilitation services.

Use InterQual criteria to support necessity determinations for outpatient cognitive rehabilitation.
Prior authorization requirements (if any) should follow InterQual-guided LOC determinations and payer-specific prior auth processes.

Denial Risk

Denial risk for coma stimulation

Coma Stimulation (also known as coma arousal, coma responsiveness, multisensory stimulation, and coma care therapy/programs) is considered unproven and not medically necessary for any Disorder of Consciousness (DOC). Services of this type are at high risk for denial.

Coma stimulation services (e.g., S9056) may be denied as not medically necessary for DOC.

Background and Clinical Context

Cognitive rehabilitation is a multidisciplinary outpatient program that uses restorative and compensatory approaches to address deficits in memory, attention, executive function, language, visuoperception and related domains. The program is designed to improve cognitive function and retrain an individual's ability to think, use judgment, and make decisions with the goal of maximizing functional independence in outpatient settings.

Definitions

Cognitive Rehabilitation (CR) — definition of 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; includes restorative and compensatory tasks to maximize functional independence (Hayes, 2017; updated 2021).

SettingOutpatient multidisciplinary program (policy applies to outpatient CR only)

GoalsReinforce or reestablish previously learned behaviors or establish new compensatory mechanisms for impaired neurologic systems to maximize functional independence

Coma Stimulation — definition describing multimodal sensory stimulation to speed recovery from coma

Term

Policy Revision History

2025-12-01title_and_definitions_revisionLatest

Title changed (previously 'Cognitive Rehabilitation (for New Mexico Only)'); language revised to state that Coma Stimulation is unproven and not medically necessary for any Disorder of Consciousness (DOC) rather than specifically for comatose, vegetative, or minimally conscious states; definition of 'Disorder of Consciousness (DOC)' added; definitions of Coma/Persistent Vegetative State and Minimally Conscious State removed.

supporting_information_updated

Description of Services, Clinical Evidence, and References were updated and the previous policy version CS020NM.B was archived.

Policy Summary

PayerUnitedHealthcare

PolicyCognitive Rehabilitation and Coma Stimulation (for New Mexico Only)

Policy CodePolicy CS020NM.C

Change TypeDefinitions and title updatedDOC addedprior definitions removed

Effective DateDec 1, 2025

Next Review DateN/A

Key ActionUse InterQual LOC: Outpatient Rehabilitation & Chiropractic to establish medical necessity for outpatient cognitive rehabilitation and verify member benefits prior to authorization.

SourceLink

On This Page

Do not bill coma stimulation as a substitute for evidence-based cognitive rehabilitation interventions.

Billing Rule

Coding and documentation notes

Claims must include appropriate CPT/HCPCS codes and sufficient clinical documentation that references the InterQual LOC rationale when applicable. Include time-based documentation for 97129/97130 and clearly document goals, interventions, and progress.

Include CPT 97129 (initial 15 minutes) and 97130 (each additional 15 minutes) when billing cognitive therapeutic interventions.
If used, list HCPCS S9056 (coma stimulation) but expect denials; document rationale if billed.
Reference InterQual LOC findings in clinical documentation to support medical necessity determinations.

Documentation Required

Documentation and benefit verification

Verify member benefits, federal/state/contractual coverage requirements, and any UnitedHealthcare-specific utilization management tools before providing services. This policy is informational and coverage may vary by contract; in case of conflict, the federal, state or contractual requirements govern.

Check member benefits and eligibility prior to scheduling services.
Use UnitedHealthcare and third-party tools (e.g., InterQual) as applicable to support benefit determinations.
Providers are responsible for documenting how services meet contractual, state, or federal benefit requirements.

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

Alternate namesAlso referred to as coma arousal, coma responsiveness, multisensory stimulation, and coma care therapy/programs

Evidence noteLacks established protocols and definitive patient selection criteria per policy clinical evidence sections

Disorder of Consciousness (DOC) — definition describing coma, vegetative state, minimally conscious state (from chunk 4)

TermDisorder of Consciousness (DOC)

DefinitionA state of prolonged altered consciousness, which can be categorized into coma, vegetative state, or minimally conscious state based on neurobehavioral function (Eapen et al., 2017).

ScopeUsed in policy to group prolonged altered consciousness states under a single definition

Disorder of Consciousness (DOC) — added definition (exact wording in policy)

Added definition (policy text)Disorder of Consciousness (DOC) — definition added to the policy.

Policy language changeReplaced previous wording specifying comatose, vegetative, or minimally conscious states with language that 'Coma Stimulation ... is unproven and not medically necessary for any Disorder of Consciousness (DOC)'.

Definitions removedRemoved prior definitions for Coma/Persistent Vegetative State and Minimally Conscious State

Effective date of change12/01/2025 (Policy History/Revision Information)