CurrentUnitedHealthcarePolicy 2025T0144FF

Outpatient Cognitive Rehabilitation and Coma Stimulation

Governs outpatient cognitive rehabilitation services and the use of coma stimulation for UnitedHealthcare Commercial and Individual Exchange members; applies to providers delivering outpatient CR and references member benefit documents for inpatient services.

Policy Summary

PayerUnitedHealthcare

PolicyOutpatient Cognitive Rehabilitation and Coma Stimulation

Policy CodePolicy 2025T0144FF

Change TypeTemplate update / application change

Effective DateMay 1, 2025

Next Review Date

Key ActionDocument outpatient Cognitive Rehabilitation services per InterQual LOC: Outpatient Rehabilitation & Chiropractic when requesting coverage; note that coma stimulation (HCPCS S9056) is designated not medically necessary.

SourceLink

POLICY UPDATE CHANGES

Created shared policy version to support application to Rocky Mountain Health Plans membership and removed language indicating this Medical Policy does not apply to the state of Colorado.

Outpatient onlyScope

Not medically necessaryComa stimulation stance

97129/97130/S9056Primary codes

InterQual referencedClinical criteria

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Coverage Criteria

Cognitive Rehabilitation - Covered with criteria

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

InterQual-based medical necessity: Outpatient Cognitive Rehabilitation is medically necessary when the clinical coverage criteria in the InterQual LOC: Outpatient Rehabilitation & Chiropractic are met.

Refer to InterQual for the specific clinical criteria and level-of-care determinations.

Coma Stimulation (also called coma arousal, multisensory stimulation, or coma care programs) is designated as unproven and not medically necessary for any indication. The policy cites insufficient evidence of efficacy for use in individuals who are comatose, in a Vegetative State, or in a Minimally Conscious State, and notes there are no established protocols or definitive patient selection criteria for these programs.

Providers should expect claims for services described as coma stimulation (for example HCPCS code S9056) to be subject to denial consistent with this not-medically-necessary determination.

The American Academy of Neurology (AAN) 2018 practice guideline (reaffirmed 2021) on disorders of consciousness does not address stimulation as a treatment modality for patients with a prolonged disorder of consciousness. The guideline advises counseling families about the limitations of existing evidence for interventions that lack support and notes there are no established therapies for children with prolonged disorders of consciousness.

Based on the available evidence and absence of standardized protocols or validated patient selection criteria, the policy considers Coma Stimulation to be unproven and not medically necessary. The documentation describes the intervention as multimodal sensory input intended to promote awakening but explicitly states there are no established protocols to demonstrate efficacy.

A Cochrane review of cognitive training and cognitive rehabilitation (CR) for mild to moderate Alzheimer disease and vascular dementia included 11 trials of cognitive training and found no evidence that cognitive training improved cognition, mood, or activities of daily living (ADLs). The review concluded that higher-quality trials are needed to establish efficacy of these interventions in this population.

Coding and Billing

Covered CPT Codes (listed for reference)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 CodeHCPCSNot Covered

S9056

Coma stimulation per diem

Billing unit — CPT timing and units

Billing unit97129 — initial 15 minutes; 97130 — each additional 15 minutes.

Code 97129 descriptionTherapeutic interventions that focus on cognitive function... direct (one-on-one) patient contact; initial 15 minutes.

Code 97130 descriptionTherapeutic 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).

Actions for Providers / Billing Guidance

Note

Policy application and template update

Policy template and application update: This policy was updated (05/01/2025) as a template revision and to create a shared policy version for application to Rocky Mountain Health Plans membership. Providers should refer to the updated shared policy version for current application details and any plan-specific variations.

Effective Date: 2025-05-01
Reference shared policy version for plan-specific application

Denial Risk

Evidence limitations may affect coverage

Evidence limitations may affect coverage decisions: Interventions lacking sufficient evidence (for example, coma stimulation and other stimulation approaches for prolonged disorders of consciousness) have limited or no support in the literature and may be considered not medically necessary. Providers should document clinical rationale and supporting evidence when requesting coverage for interventions with limited evidence.

Interventions lacking strong evidence may be denied or considered not medically necessary
Families should be counseled regarding limitations of existing evidence

Documentation Required

Providers should document outpatient CR services per InterQual LOC

Document outpatient Cognitive Rehabilitation (CR) per InterQual criteria: Outpatient CR services are considered medically necessary only when they meet the InterQual® LOC: Outpatient Rehabilitation & Chiropractic criteria. Providers must document patient assessments, treatment goals, specific therapeutic interventions (e.g., CPT 97129/97130), time units, progress toward goals, and justification that care meets InterQual medical necessity thresholds.

Document use of CPT 97129 and 97130 with time-based units and clinical justification
Attach InterQual-based medical necessity rationale to prior authorization or claim when applicable

Denial Risk

Coma stimulation is not medically necessary

Coma stimulation (e.g., HCPCS S9056) is unproven and not medically necessary: Coma stimulation services are considered experimental/unproven due to insufficient evidence of efficacy for any indication (including comatose, vegetative, or minimally conscious states). Claims for coma stimulation (HCPCS code S9056) may be denied; providers should avoid billing for these services as covered outpatient CR.

HCPCS S9056 — Coma stimulation per diem — Not medically necessary / experimental
Claims for coma stimulation risk denial

Note

Provider actions — plan or document-specific items not specified here

Not specified in this document excerpt: If additional provider actions or plan-specific billing instructions are required, providers should consult the member-specific benefit plan document and the payer's provider portal for any missing operational details.

Refer to member-specific benefit documents for coverage determinations
Contact payer/provider portal for missing billing instructions

Key Definitions

Cognitive Rehabilitation (CR)

DefinitionA multidisciplinary treatment program designed to improve cognitive function and retrain an individual's ability to think, use judgment and make decisions; includes restorative and compensatory tasks to maximize functional independence.

Targeted domainsMemory, attention, perception, visual processing, language, reasoning, learning, planning, judgment, and problem-solving.

Treatment approachIncludes tasks to reinforce or reestablish previously learned behaviors or establish compensatory mechanisms for impaired neurologic systems.

Coma Stimulation

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

Protocol statusNo established protocols for coma stimulation are described in the policy.

SynonymsAlso referred to as coma arousal, coma responsiveness, multisensory stimulation.

Coma / Persistent Vegetative State (PVS)

DefinitionA long, deep state of unconsciousness in which a person is alive but unable to move or respond to their surroundings.

SourceDefined per NINDS as used in Medicare Advantage policy section.

Clinical noteIndividuals in this state are not responsive to environment despite being alive.

Minimally Conscious State

DefinitionA condition with limited awareness of self and environment; the individual is awake and occasionally able to communicate or perform simple voluntary activities.

Clinical featuresResidual cognitive functions allow intermittent engagement with surroundings (may show simple voluntary activity).

ContextOccurs after severe brain injury or deterioration.

Cognitive Rehabilitation (regulatory note)

DefinitionTherapeutic interventions aimed at improving cognitive functioning; described as therapy and not subject to FDA regulation.

Regulatory noteCognitive Rehabilitation is not subject to FDA regulation; FDA approval status is not a basis for coverage decisions.

PurposeImprove deficits in cognitive domains and maximize functional independence through restorative or compensatory approaches.

Disorders of consciousness

DefinitionProlonged disorders (e.g., coma or persistent vegetative state) where there are limited established therapies and evidence for stimulation interventions is limited.

AAN guidanceAAN practice guideline does not address stimulation as a treatment modality for prolonged disorders of consciousness and recommends counseling families about limited evidence.

Evidence implicationLack of established therapies for children with prolonged disorders of consciousness noted in guideline.

Background and Evidence Summary

Cognitive Rehabilitation (CR) is a multidisciplinary therapeutic program aimed at improving cognitive domains such as memory, attention, executive function, language, and visuoperceptual ability. CR uses both restorative approaches — exercises to reinforce or restore impaired skills — and compensatory strategies that teach ways to bypass deficits and maximize functional independence.

CR may be delivered using a variety of modalities, and emerging approaches such as virtual reality are being explored; however, the policy notes there are currently no established device protocols or definitive patient selection criteria for many of these modalities.