Y-21-019

HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

Medical Policy:

Y-21-019

Topic:

Cognitive Rehabilitation

Section:

Therapy

Effective Date:

October 1, 2023

Issued Date:

October 1, 2023

Last Revision Date:

September 2023

Annual Review:

November 2022

Cognitive rehabilitation describes therapeutic activities designed to improve cognitive function and retrain an individual's ability to think, use judgment and make decisions. The focus of these therapeutic activities is to improve deficits in memory, attention, perception, visual processing, language, reasoning, learning, planning, judgment, and problem-solving.

Policy Position

Cognitive rehabilitation, as a distinct and definable component of the rehabilitation process, may be considered medically necessary for the rehabilitation of traumatic and acquired brain injury including but not limited to brain hemorrhage, cerebral thrombosis, concussion, fractured skull and post-traumatic encephalopathy, anoxic brain damage and infectious disease such as encephalitis.

Cognitive rehabilitation may be considered medically necessary for individuals who are able to interactively participate in the therapy and are expected to make significant cognitive improvement and ALL of the following:

The services must be ordered by the attending physician or neuropsychologist and be part of a written plan of care; and
The service is so complex that it can only be performed by a qualified licensed professional; and
The individual is capable of actively participating in the program and capable, by mental status, of demonstrating responsiveness to verbal or visual stimuli and able to follow commands and process and retain information; and
The individual’s mental and physical condition prior to the injury indicates there is significant potential for improvement (e.g., a complete recovery of pre-injury memory, language or reasoning skills is not required, but there must be a reasonable expectation of improvement that is of practical value to the individual, measured against the individual’s condition at the start of the rehabilitation program), and the individual must have no lasting or major treatment impediment that prevents progress, such as severe dementia; and
The individual is expected to show measurable functional improvement within a predetermined timeframe (depending on the underlying diagnosis or medical condition) from the start of cognitive rehabilitation therapy. Goals and expected timeframes can be addressed before the onset of treatment; and
The attending physician must review the treatment plan periodically to assess the continued need for participation and document objective evidence of the individuals progress; and
Neuropsychological testing preformed by a neuropsychiatrist, neuropsychologist or behavioral neurologist and neuropsychological results will be used in treatment-planning and redirecting rehabilitation strategies.

Cognitive rehabilitation not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

A maintenance therapy program includes activities that maintain the individual’s present level of function and prevent regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved or when no further functional progress is apparent or expected to occur. Maintenance therapy is not an eligible service.

97129

97130

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S06.366A	S06.366D	S06.366S	S06.367A	S06.367D	S06.367S	S06.368A
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S06.813A	S06.813D	S06.813S	S06.814A	S06.814D	S06.814S	S06.815A
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S06.A1XA	S06.A1XD	S06.A1XS	T75.1XXA	T75.1XXD	T75.1XXS

Place of Service: Inpatient/Outpatient

Cognitive Rehabilitation is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business

Links

Link to References

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages
If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.