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Cognitive Rehabilitation

Policy Number: MP-600

Latest Review Date: March 2024

Category:  Therapy                                                    

POLICY:

Cognitive/Neurobehavioral/Neurorestorative Rehabilitation (as a distinct and definable component of the rehabilitation process) is considered investigational for any indication, including but not limited to:

  • traumatic brain injury
  • dementia (including Alzheimer Disease)
  • post-encephalopathy
  • stroke
  • epilepsy/seizure disorders
  • Autism Spectrum Disorders
  • multiple sclerosis
  • post-acute cognitive sequelae of SARS-CoV-2 infection
  • cancer

*Note: There are varying benefit plans for these services. Please verify benefits prior to applying policy criteria, as benefit coverage will supersede this policy.

DESCRIPTION OF PROCEDURE OR SERVICE:

Cognitive rehabilitation sometimes referred to as neurobehavioral or neurorestorative rehabilitation is a therapeutic approach designed to improve cognitive functioning after central nervous system insult. It includes an assembly of therapy methods intended to retrain or improve deficits in attention, visual processing, language, memory, reasoning, problem solving, and executive functions. Cognitive rehabilitation comprises tasks to reinforce or re-establish previously learned patterns of behavior or to establish new compensatory mechanisms for impaired neurologic systems. A physician, psychologist, or a physical, occupational, or speech therapist may perform cognitive rehabilitation.

The term cognitive rehabilitation is applied to various intervention strategies or techniques that attempt to help individuals reduce, manage, or cope with cognitive deficits caused by brain injury. The desired outcome of cognitive rehabilitation is to improve the quality of life or to improve the ability to function in the home and community life. The term rehabilitation broadly encompasses reentry into familial, social, educational, and working environments, the reduction of dependence on assistive devices or services, and the general enrichment of quality of life. Cognitive rehabilitation is considered a separate service from other rehabilitative therapies, with its own specific procedures.

Sensory and auditory integrative therapy and constraint induced movement or language therapy may be considered components of cognitive rehabilitation. However, sensory and auditory integration therapy is considered separately in medical policy #333 Sensory Integration Therapy and Auditory Integration Therapy, and constraint induced movement or language therapy is considered in medical policy #188 Constraint Induced Movement or Language Therapy.

KEY POINTS:

The most recent update with literature review covered the period through February 1, 2024.

Summary of Evidence

For individuals who have cognitive deficits due to TBI who receive cognitive rehabilitation delivered by a qualified professional, the evidence includes RCTs, non-randomized comparison studies, case series, and systematic reviews. Relevant outcomes are functional outcomes and quality of life. The cognitive rehabilitation trials have methodologic limitations and have reported mixed results, indicating there is no uniform or consistent evidence base supporting the efficacy of this technique. Systematic reviews have generally concluded that efficacy of cognitive rehabilitation is uncertain. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have cognitive deficits due to dementia who receive cognitive rehabilitation delivered by a qualified professional, the evidence includes RCTs, non-randomized comparison studies, case series, and systematic reviews. Relevant outcomes are functional outcomes and quality of life.  A Cochrane systematic review of cognitive rehabilitation including trials conducted between 2010 and 2022 focusing on outcomes related to everyday function found statistically significantly improved participant self-ratings of goal attainment related to everyday functioning both immediately following rehabilitation and after 3 to 12 months follow-up post-rehabilitation. There was less certainty regarding whether cognitive rehabilitation had a meaningful effect on quality of life. One large RCT evaluating a goal-oriented cognitive rehabilitation program reported a significantly less functional decline in one of two functional scales and lower rates of institutionalization in the cognitive rehabilitation group compared with usual care at 24 months. These results need replication. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have cognitive deficits due to stroke who receive cognitive rehabilitation delivered by a qualified professional, the evidence includes RCTs and systematic reviews. Relevant outcomes are functional outcomes and quality of life. Four systematic reviews evaluating three separate domains of cognitive function have shown no benefit of cognitive rehabilitation or effects of clinical importance. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have cognitive deficits due to MS who receive cognitive rehabilitation delivered by a qualified professional, the evidence includes RCTs and systematic reviews. Relevant outcomes are functional outcomes and quality of life. Systematic reviews of RCTs have shown no significant effects of cognitive rehabilitation on cognitive outcomes. Although numerous RCTs have investigated cognitive rehabilitation for MS, high-quality trials are lacking. The ability to draw conclusions based on the overall body of evidence is limited by the heterogeneity of individual samples, interventions, and outcome measures. Further, results of the available RCTs have been mixed, with positive studies mostly reporting short-term benefits. Evidence for clinically significant, durable improvements in cognition is currently lacking. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have cognitive deficits due to epilepsy, ASD, post-encephalopathy, or cancer who receive cognitive rehabilitation delivered by a qualified professional, the evidence includes RCTs, non-randomized comparison studies, and case series. Relevant outcomes are functional outcomes and quality of life. The quantity of studies for these conditions is much less than that for the other cognitive rehabilitation indications. Systematic reviews generally have not supported the efficacy of cognitive rehabilitation for these conditions. Relevant RCTs have had methodologic limitations, most often very short lengths of follow-up, which do not permit strong conclusions about efficacy. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have cognitive deficits due to post-acute sequelae of SARS-CoV-2 infection who receive cognitive rehabilitation delivered by a qualified professional, no relevant evidence was identified. Relevant outcomes are functional outcomes and quality of life. Systematic reviews have reported on the prevalence and duration of cognitive symptoms among individauls with varying acute infection severity and treatment settings. Limited reports examining the outcomes of rehabilitation in individauls with post-acute COVID19 have primarily focused on physical and respiratory rehabilitation. Additionally, the natural history of cognitive deficits experienced by individuals who have recovered from acute COVID-19 requires further elucidation. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Practice Guidelines and Position Statements

American Academy of Physical Medicine and Rehabilitation

In 2021, the American Academy of Physical Medicine and Rehabilitation (AAPM&R) Multi-Disciplinary Post-Acute Sequelae of SARS-CoV-2 Infection (PASC) Collaborative issued a consensus guidance statement on the assessment and treatment of cognitive symptoms in patients with PASC. PASC cognitive symptom assessment and treatment recommendations are summarized in Table 1.

Table 1. Post-Acute Sequelae of SARS-CoV-2 Infection Cognitive Symptom Assessment and Treatment Recommendationsa

Assessment Recommendations

Recommendation #

Statement

1

"Patients should be screened for signs of cognitive symptoms using validated tools and instruments."

2

"Patients should be evaluated for conditions that may exacerbate cognitive symptoms and warrant further testing and potential subspecialty referral. [...] Particular areas include:

  • Sleep impairment
  • Mood, including anxiety, depression, and posttraumatic stress disorder
  • Fatigue
  • Endocrine abnormalities
  • Autoimmune disorders

Note: Patients often report dissatisfaction with their care because of their persistent symptoms being attributed to psychological factors. It is important to note that mood disorders may be secondary to persistent medical conditions or one of many factors leading to cognitive symptoms."

3

"Patients should have a thorough neurological examination to identify focal neurological deficits."

3a

"For those patients identified with new or worsening focal neurological deficits (including new or worsening cognitive symptoms) an emergent evaluation is warranted; neuroimaging should be considered."

4

"The following basic lab workup should be considered to screen for reversible factors contributing to cognitive symptoms. The initial lab work up in new patients or those without lab work up in the 3 months prior to visit including complete blood count, vitamin B12, thiamine, folate, homocysteine, 1,25-dihydroxy vitamin D, magnesium, liver function tests, comprehensive metabolic panel thyroid function tests (thyroid stimulating hormone, free T3, free T4). In high-risk patients, one may consider syphilis rapid plasma regain and human immunodeficiency virus testing [...]"

5

"Clinicians should conduct a full patient history with review of preexisting conditions and comprehensive medication and supplement review for those that may contribute to cognitive symptoms.

Of note, patients with PASC often present on antihistamine, anticholinergic, and antidepressant/anxiolytic medications that can contribute to cognitive symptoms."

5a

"Clinicians should validate patient history through the collection of collateral history, including preexisting function and conditions, from care team/primary care, patient family or care partner, or close contact as available."

6

"Clinicians should assess impact of cognitive symptoms using standardized patient-reported assessments, to include activities of daily living, instrumental activities of daily living, school, work and avocational (i.e., hobbies), and quality of life."

Treatment Recommendations

Recommendation #

Statement

1

"For patients who screen positive for cognitive symptoms, refer to a specialist (i.e., speech-language pathologist, occupational therapist, neuropsychologist) with expertise in formal cognitive assessment and remediation."

2

"Treat, in collaboration with appropriate specialists, underlying medical conditions, such as pain, insomnia/sleep disorders (including poor sleep hygiene), and mood disorders that may be contributing to cognitive symptoms."

3

"Complete, in collaboration with patient primary care provider, medication polypharmacy reduction, weaning or deprescribing medications if medically feasible with emphasis on medications that may impact cognition."

4

"Reinforce sleep hygiene techniques including non-pharmacologic approaches as first line of sleep remediation."

5

"Similar to patients experiencing “physical” fatigue, patients should be advised to begin an individualized and structured, titrated return to activity program."

5a

"For patients who achieve a return to their normal, daily activities, regular exercise (at least 2–3 times/week of aerobic exercise) may be effective in improving cognition and also contribute to improved sleep patterns."

5b

 "Frequent assessment of the impact of return to normal, daily activities (including school, work, driving, operating heavy machinery, etc.) is recommended to ensure that symptoms do not flare and exercise is tolerated."

a Adapted from Fine et al (2021)

 

In 2023, the American Academy of Physical Medicine and Rehabilitation (AAPM&R) Multi-Disciplinary Post-Acute Sequelae of SARS-CoV-2 Infection (PASC) Collaborative issued a consensus guidance statement on the assessment and treatment of neurologic symptoms in individuals with PASC.  PASC neurologic symptom assessment and treatment recommendations are summarized in Table 2.

Table 2 Post-Acute Sequelae of SARS-CoV-2 Infection Neurologic Symptom Assessment and Treatment Recommendationsa

Assessment Recommendations
Recommendations #  Statement
1 "Clinicians should conduct a full patient history including a review of predisposing comorbidities, prior neurologic symptoms or disorders, relevant hospitalizations, time course and severity of COVID-19 infection(s), COVID-19 treatments, vaccines/boosters, pertinent family history, and social history."
2 "Clinicians should perform a thorough neurological examination to identify focal neurological deficits."
3 "Evaluate for medication and supplement use that may impact signs, symptoms, or assessment parameters"
4 "The following basic lab workup should be considered in new patients or for those without a lab workup in the 3  months prior to the visit: complete blood count with differential; chemistries including renal and hepatic function tests, thyroid stimulating hormone, c-reactive protein, erythrocyte sedimentation rate, vitamins B1, B6, B12, and D, magnesium, and hemoglobin A1c (HbA1c)."
5 "Assess for history of previous and/or current alcohol and substance use, current diet and exercise habits, physical and cognitive activity levels, and social determinants of health (eg, housing, employment, family, insurance, access to community resources, social stressors, etc.)"
6 "Assess for changes in basic and instrumental activities of daily living, including participation at work, school, community avocational (ie, hobbies) activities."
7 "On initial evaluation, obtain standardized measures of activity performance to compare to normal control values and to guide the initial activity prescription. Repeat the standardized measures of activity performance at follow-up visits to quantify functional changes and guide progression of the activity prescription."
Treatment Recommendations
Recommendation # Statement
1 "In collaboration with primary care or appropriate specialist treat underlying medical conditions, such as pain, psychiatric, renal/endocrine, cardiovascular, neurological, respiratory, etc., which may be contributing to neurologic symptoms."
2 "In collaboration with primary care or appropriate specialist, consider polypharmacy reduction, weaning or deprescribing medications and supplements where medically feasible."
3 "For patients who achieve a return to their daily activities, consider recommending regular physical activity as tolerated, which may be effective in improving many neurologic symptoms and also contribute to improved sleep patterns."
4 "For patients with neurologic sequelae affecting gait, mobility, cognitive status or activities of daily living, consider referral to physical medicine and rehabilitation physician and/or allied health professionals (eg, physical therapy, occupational therapy, speech language pathology and social work) for patient-specific recommendations to increase function and independence. To optimize functional outcomes, allied health professionals should preferably be familiar with treating sensorimotor deficits, autonomic dysfunction, and post-exertional fatigue."
5 "Provide counseling, referrals to community resources, and education for risk factor modification in the areas of: alcohol and substance use; healthy dietary pattern and hydration; return to activity, as tolerated; medications and supplements; sleep hygiene; social determinants of health."

 aAdapted from Melamed et al (2023)

American Congress of Rehabilitation Medicine

In 2013, based on a systematic review,  the American Congress of Rehabilitation recommended process-based cognitive rehabilitation strategies (e.g., attention process training, strategy acquisition and internalization, self-monitoring, and corrective feedback) to treat attention and memory deficits in children and adolescents with brain cancers who undergo surgical resection and/or radiotherapy. The strength of evidence for recommendations were determined according to the American Academy of Neurology study classification, and no financial conflicts of interest were declared by the authors.

National Institute for Health and Care Excellence

 In 2013 (updated in 2023), NICE on stroke rehabilitation recommended cognitive rehabilitation for visual neglect and memory and attention deficits that impact function. Interventions should focus on relevant functional tasks (e.g., error less learning) and "elaborative techniques" (e.g., "mnemonics", "encoding strategies") for memory impairments. The guidance states that providers should 'Make special arrangements for people after stroke who have communication or cognitive needs (for example, by holding joint speech and language therapy and physiotherapy sessions for those with communication difficulties).'

In 2018, NICE guidance on dementia management suggested: "Consider cognitive rehabilitation or occupational therapy to support functional ability in people living with mild to moderate dementia." 

In 2021 (updated in 2024), NICE issued a rapid guideline on managing the long-term effects of COVID-19. The guideline recommends using a "multidisciplinary approach to guide rehabilitation, including physical, psychological and psychiatric aspects of management." Cognitive rehabilitation was not specifically addressed. Assessing the clinical effectiveness of "different service models of multimodality/multidisciplinary post-COVID-19 syndrome rehabilitation in improving patient-reported outcomes (such as quality of life)" was listed as a key recommendation for research.

Institute of Medicine

In 2011, the Institute of Medicine published a report on cognitive rehabilitation for traumatic brain injury that included a comprehensive review of the literature and recommendations. The report concluded that “current evidence provides limited support for the efficacy of CRT (cognitive rehabilitation therapy) interventions. The evidence varies in both the quality and volume of studies and therefore is not yet sufficient to develop definitive guidelines for health professionals on how to apply CRT in practice.” The report recommended that standardization of clinical variables, intervention components, and outcome measures was necessary to improve the evidence base for this treatment. The Institute of Medicine also recommended future studies with larger sample sizes and more comprehensive sets of clinical variables and outcome measures.

Veterans Administration

In 2009, the Veterans Administration/Department of Veterans Affairs published guidelines on the treatment of concussion and mild traumatic brain injury, which were updated in 2016 and most recently in 2021. These guidelines addressed cognitive rehabilitation in the setting of persistent symptoms. The 2021 guidelines stated:

  • "We suggest that patients with symptoms attributed to mild traumatic brain injury [mTBI] who present with memory, attention, or executive function problems despite appropriate management of other contributing factors (e.g., sleep, pain, behavioral health, headache, disequilibrium) should be referred for a short trial of clinician-directed cognitive rehabilitation services." [Strength of recommendation: "weak for."]
  • "We suggest against the use of self-administered computer training programs for the cognitive rehabilitation of patients with symptoms attributed to mTBI." [Strength of recommendation: "weak against."]

A 2019 Veterans Administration/Department of Defense practice guideline on the management of stroke rehabilitation found "insufficient evidence to recommend for or against the use of any specific cognitive rehabilitation methodology or pharmacotherapy to improve cognitive outcomes" and noted "there has been very little advancement in the evidence regarding the use of specific cognitive rehabilitation strategies or techniques to improve clinical outcomes following stroke.

U.S. Preventive Services Task Force Recommendations

Not Applicable.

KEY WORDS:

Cognitive Rehabilitation, Neurobehavioral, Neurorestorative, neuropsychological testing

APPROVED BY GOVERNING BODIES:

Cognitive rehabilitation is not a U.S. Food and Drug Administration-regulated procedure.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply.

FEP:  Special benefit consideration may apply.  Refer to member’s benefit plan. 

CURRENT CODING:

CPT Codes:

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

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; each additional 15 minutes (List separately in addition to code for primary procedure).

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POLICY HISTORY:

Medical Policy Panel, February 2015

Medical Policy Group, June 2015 (4):  Adoption of new policy for cognitive rehabilitation performed outside of an acute setting

Medical Policy Administration Committee, July 2015

Available for comment July 4 through August 17, 2015

Medical Policy Group, September 2015 (4): Policy statement updated to remove “when performed outside of an acute setting.” Updated Description section

Medical Policy Administration Committee, October 2015

Available for comment September 29 through November 12, 2015

Medical Policy Panel, March 2016

Medical Policy Group, March 2016 (4): Updates to Description, Key Points, and References. No change to policy statement.

Medical Policy Panel, March 2017

Medical Policy Group, March 2017 (4): Updates to Key Points and References. No change to policy statement.

Medical Policy Group, December 2017: Annual Coding Update 2017: Added new CPT code 97127 and new HCPCS code G0515 to Current Coding. Created Previous Coding section and moved deleted CPT code 97532 to this section.

Medical Policy Panel, March 2018

Medical Policy Group, March 2018 (4): Updates to Key Points, and References.  No change to policy statement.

Medical Policy Panel, March 2019

Medical Policy Group, April 2019 (4):  Updates to Key Points. Removed effective for dates of service on and after July 4, 2015 and prior to November 13, 2015 from policy section.

Medical Policy Group, December 2019: 2020 Annual Coding Update.  Added new CPT codes 97129 and 97130 to Current Coding. Moved CPT code 97127 and HCPCS code G0515 from Current Coding to Previous Coding.

Medical Policy Panel, March 2020

Medical Policy Group, March 2020 (3): 2020 Updates to Key Points, Practice Guidelines and Position Statements, and References. No changes to policy statement or intent.

Medical Policy Panel, March 2021

Medical Policy Group, April 2021 (3): 2021 Updates to Key Points and References. Policy statement updated to remove “not medically necessary,” no change to policy statement or intent.

Medical Policy Panel, March 2022

Medical Policy Group, March 2022 (3): 2022 Updates to Key Points, Practice Guidelines and Position Statements, and References. Added the diagnosis of post-acute cognitive sequelae of SARS-CoV-2 infection to the investigational statement of the policy. No other changes to policy statement or intent.

Medical Policy Panel, March 2023

Medical Policy Group, March 2023 (3): 2023 Updates Key Points, Practice Guidelines and Position Statements, Benefit Applications, and References. Title changed from Cognitive/Neurobehavioral/Neurorestorative Rehabilitation to Cognitive Rehabilitation. Previous Coding section removed. No changes to policy statements or intent.

Medical Policy Panel, March 2024

Medical Policy Group, March 2024 (3): Updates to Description, Key Points, Benefit Application, and References. No changes to policy statements or intent.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.