660 Form

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Medical Policy Cognitive Rehabilitation Table of Contents
• Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History
• Endnotes Policy Number: 660
BCBSA Reference Number: 8.03.10 (For Plan internal use only) NCD/LCD: N/A
Related Policies
Sensory Integration Therapy and Auditory Integration Therapy, #659 Policy
Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Cognitive rehabilitation (as a distinct and definable component of the rehabilitation process) may be considered MEDICALLY NECESSARY in the rehabilitation of individuals with cognitive impairment due to traumatic brain injury.

Per state mandate Chapter 260 of the Acts of 2020 – Patients First Act, cognitive rehabilitation for cognitive impairment resulting from COVID-19 is covered in the outpatient setting.1

Providers should document ALL of the following for coverage: • Cognitive impairments resulted from COVID-19 that was either clinically diagnosed or diagnosed through PCR/Antigen testing, AND • Patient symptoms impair daily functioning and are unlikely to resolve on their own over time, AND • Patient symptoms are expected to improve with cognitive rehabilitation.

Inpatient cognitive rehabilitation for cognitive impairment resulting from COVID-19 is not covered unless the individual otherwise meets criteria for inpatient level of care.

Cognitive rehabilitation (as a distinct and definable component of the rehabilitation process) is considered INVESTIGATIONAL for all other applications, including, but not limited to, stroke, postencephalitic or post encephalopathic individuals, autism spectrum disorder, seizure disorders, multiple sclerosis, the aging population, including individuals with Alzheimer disease, and individuals with cognitive deficits due to brain tumor or previous treatment for cancer.

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Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for situations where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required. Medicare HMO BlueSM Prior authorization is not required. Medicare PPO BlueSM Prior authorization is not required.

CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue: CPT Codes CPT codes:

Code Description 97129 Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, 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 (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, 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) The following ICD Diagnosis Codes are considered medically necessary when submitted with the CPT code above if medical necessity criteria are met: ICD-10 Diagnosis Coding ICD-10-CM diagnosis codes: Code Description S01.90XA Unspecified open wound of unspecified part of head, initial encounter

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S01.90XD Unspecified open wound of unspecified part of head, subsequent encounter S01.90XS Unspecified open wound of unspecified part of head, sequela S06.330A Contusion and laceration of cerebrum, unspecified, without loss of consciousness, initial encounter S06.330D Contusion and laceration of cerebrum, unspecified, without loss of consciousness, subsequent encounter S06.330S Contusion and laceration of cerebrum, unspecified, without loss of consciousness, sequela S06.331A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, initial encounter S06.331D Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, subsequent encounter S06.331S Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, sequela S06.332A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, initial encounter S06.332D Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter S06.332S Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, sequela S06.333A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter S06.333D Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 1 hour to 5 hours 59 minutes, subsequent encounter S06.333S Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela S06.334A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, initial encounter
S06.334D Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, subsequent encounter S06.334S Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, sequela S06.335A Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter S06.335D Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours with return to pre-existing conscious level, subsequent encounter S06.335S Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela S06.336A Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter S06.336D Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter S06.336S Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, sequela S06.337A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter S06.338A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter

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S06.339A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of unspecified duration, initial encounter S06.339D Contusion and laceration of cerebrum, unspecified, with loss of consciousness of unspecified duration, subsequent encounter
S06.339S Contusion and laceration of cerebrum, unspecified, with loss of consciousness of unspecified duration, sequela S06.360A Traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness, initial encounter S06.360D Traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness, subsequent encounter S06.360S Traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness, sequela S06.361A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, initial encounter S06.361D Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, subsequent encounter S06.361S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, sequela S06.362A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, initial encounter S06.362D Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter S06.362S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, sequela S06.363A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 1 hours to 5 hours 59 minutes, initial encounter S06.363D Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 1 hours to 5 hours 59 minutes, subsequent encounter S06.363S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 1 hours to 5 hours 59 minutes, sequela S06.364A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, initial encounter S06.364D Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, subsequent encounter S06.364S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, sequela S06.365A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, sequela S06.365D Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness greater than 24 hours with return to pre-existing conscious level, subsequent encounter S06.365S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela S06.366A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela S06.366D Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter S06.366S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, sequela S06.367A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter

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S06.368A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter S06.369A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of unspecified duration, initial encounter S06.369D Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of unspecified duration, subsequent encounter S06.369S Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of unspecified duration, sequela S06.370A Contusion, laceration, and hemorrhage of cerebellum without loss of consciousness, initial encounter S06.370D Contusion, laceration, and hemorrhage of cerebellum without loss of consciousness, subsequent encounter S06.370S Contusion, laceration, and hemorrhage of cerebellum without loss of consciousness, sequela S06.371A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 30 minutes or less, initial encounter S06.371D Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 30 minutes or less, subsequent encounter S06.371S Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 30 minutes or less, sequela S06.372A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 31 minutes to 59 minutes, initial encounter S06.372D Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter S06.372S Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 31 minutes to 59 minutes, sequela S06.373A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter S06.373D Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 1 hour to 5 hours 59 minutes, subsequent encounter S06.373S Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela S06.374A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 6 hours to 24 hours, initial encounter S06.374D Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 6 hours to 24 hours, subsequent encounter S06.374S Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 6 hours to 24 hours, sequela S06.375A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter S06.375D Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, subsequent encounter S06.375S Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela S06.376A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter S06.376D Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter

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S06.376S Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, sequela S06.377A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter S06.378A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter S06.379A Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of unspecified duration, initial encounter S06.379D Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of unspecified duration, subsequent encounter S06.379S Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of unspecified duration, sequela S06.380A Contusion, laceration, and hemorrhage of brainstem without loss of consciousness, initial encounter S06.380D Contusion, laceration, and hemorrhage of brainstem without loss of consciousness, subsequent encounter S06.380S Contusion, laceration, and hemorrhage of brainstem without loss of consciousness, sequela S06.381A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 30 minutes or less, initial encounter S06.381D Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 30 minutes or less, subsequent encounter S06.381S Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 30 minutes or less, sequela S06.382A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 31 minutes to 59 minutes, initial encounter S06.382D Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter S06.382S Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 31 minutes to 59 minutes, sequela S06.383A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter S06.383D Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 1 hour to 5 hours 59 minutes, subsequent encounter S06.383S Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela S06.384A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 6 hours to 24 hours, initial encounter S06.384D Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 6 hours to 24 hours, subsequent encounter S06.384S Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 6 hours to 24 hours, sequela S06.385A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter S06.385D Contusion, laceration, and hemorrhage of brainstem with loss of consciousness greater than 24 hours with return to pre-existing conscious level, subsequent encounter S06.385S Contusion, laceration, and hemorrhage of brainstem with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela

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S06.386A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter S06.386D Contusion, laceration, and hemorrhage of brainstem with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter S06.386S Contusion, laceration, and hemorrhage of brainstem with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, sequela S06.387A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter S06.388A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter S06.389A Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of unspecified duration, initial encounter S06.389D Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of unspecified duration, subsequent encounter S06.389S Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of unspecified duration, sequela S06.890A Other specified intracranial injury without loss of consciousness, initial encounter S06.890D Other specified intracranial injury without loss of consciousness, subsequent encounter S06.890S Other specified intracranial injury without loss of consciousness, sequela S06.891A Other specified intracranial injury with loss of consciousness of 30 minutes or less, initial encounter S06.891D Other specified intracranial injury with loss of consciousness of 30 minutes or less, subsequent encounter S06.891S Other specified intracranial injury with loss of consciousness of 30 minutes or less, sequela S06.892A Other specified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, initial encounter S06.892D Other specified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter S06.892S Other specified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, sequela S06.893A Other specified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter S06.893D Other specified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, subsequent encounter S06.893S Other specified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela S06.894A Other specified intracranial injury with loss of consciousness of 6 hours to 24 hours, initial encounter S06.894D Other specified intracranial injury with loss of consciousness of 6 hours to 24 hours, subsequent encounter S06.894S Other specified intracranial injury with loss of consciousness of 6 hours to 24 hours, sequela S06.895A Other specified intracranial injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
S06.895D Other specified intracranial injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, subsequent encounter

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S06.895S Other specified intracranial injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela S06.896A Other specified intracranial injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter S06.896D Other specified intracranial injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter S06.896S Other specified intracranial injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, sequela S06.899A Other specified intracranial injury with loss of consciousness of unspecified duration, initial encounter S06.899D Other specified intracranial injury with loss of consciousness of unspecified duration, subsequent encounter S06.899S Other specified intracranial injury with loss of consciousness of unspecified duration, sequela S06.1X0A Traumatic cerebral edema without loss of consciousness, initial encounter S06.1X0D Traumatic cerebral edema without loss of consciousness, subsequent encounter S06.1X0S Traumatic cerebral edema without loss of consciousness, sequela S06.1X1A Traumatic cerebral edema with loss of consciousness of 30 minutes or less, initial encounter S06.1X1D Traumatic cerebral edema with loss of consciousness of 30 minutes or less, subsequent encounter S06.1X1S Traumatic cerebral edema with loss of consciousness of 30 minutes or less, sequela S06.1X2A Traumatic cerebral edema with loss of consciousness of 31 minutes to 59 minutes, initial encounter S06.1X2D Traumatic cerebral edema with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter S06.1X2S Traumatic cerebral edema with loss of consciousness of 31 minutes to 59 minutes, sequela S06.1X3A Traumatic cerebral edema with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter S06.1X3D Traumatic cerebral edema with loss of consciousness of 1 hour to 5 hours 59 minutes, subsequent encounter S06.1X3S Traumatic cerebral edema with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela S06.1X4A Traumatic cerebral edema with loss of consciousness of 6 hours to 24 hours, initial encounter S06.1X4D Traumatic cerebral edema with loss of consciousness of 6 hours to 24 hours, subsequent encounter S06.1X4S Traumatic cerebral edema with loss of consciousness of 6 hours to 24 hours, sequela S06.1X5A Traumatic cerebral edema with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter S06.1X5D Traumatic cerebral edema with loss of consciousness greater than 24 hours with return to pre-existing conscious level, subsequent encounter S06.1X5S Traumatic cerebral edema with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela S06.1X6A Traumatic cerebral edema with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter S06.1X6D Traumatic cerebral edema with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter S06.1X6S Traumatic cerebral edema with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, sequela

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S06.1X7A Traumatic cerebral edema with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter S06.1X8A Traumatic cerebral edema with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter S06.1X9A Traumatic cerebral edema with loss of consciousness of unspecified duration, initial encounter S06.1X9D Traumatic cerebral edema with loss of consciousness of unspecified duration, subsequent encounter S06.1X9S Traumatic cerebral edema with loss of consciousness of unspecified duration, sequela S06.4X0A Epidural hemorrhage without loss of consciousness, initial encounter S06.4X0D Epidural hemorrhage without loss of consciousness, subsequent encounter S06.4X0S Epidural hemorrhage without loss of consciousness, sequela S06.4X1A Epidural hemorrhage with loss of consciousness of 30 minutes or less, initial encounter S06.4X1D Epidural hemorrhage with loss of consciousness of 30 minutes or less, subsequent encounter S06.4X1S Epidural hemorrhage with loss of consciousness of 30 minutes or less, sequela S06.4X2A Epidural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, initial encounter S06.4X2D Epidural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter S06.4X2S Epidural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, sequela S06.4X3A Epidural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter S06.4X3D Epidural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, subsequent encounter S06.4X3S Epidural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela S06.4X4A Epidural hemorrhage with loss of consciousness of 6 hours to 24 hours, initial encounter S06.4X4D Epidural hemorrhage with loss of consciousness of 6 hours to 24 hours, subsequent encounter S06.4X4S Epidural hemorrhage with loss of consciousness of 6 hours to 24 hours, sequela S06.4X5A Epidural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter S06.4X5D Epidural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, subsequent encounter S06.4X5S Epidural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela S06.4X6A Epidural hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter S06.4X6D Epidural hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter S06.4X6S Epidural hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, sequela S06.4X7A Epidural hemorrhage with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter S06.4X8A Epidural hemorrhage with loss of consciousness of any duration with death due to other causes prior to regaining consciousness, initial encounter S06.4X9A Epidural hemorrhage with loss of consciousness of unspecified duration, initial encounter S06.4X9D Epidural hemorrhage with loss of consciousness of unspecified duration, subsequent encounter

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S06.4X9S Epidural hemorrhage with loss of consciousness of unspecified duration, sequela S06.5X0A Traumatic subdural hemorrhage without loss of consciousness, initial encounter S06.5X0D Traumatic subdural hemorrhage without loss of consciousness, subsequent encounter S06.5X0S Traumatic subdural hemorrhage without loss of consciousness, sequela S06.5X1A Traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, initial encounter S06.5X1D Traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, subsequent encounter S06.5X1S Traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, sequela S06.5X2A Traumatic subdural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, initial encounter S06.5X2D Traumatic subdural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter S06.5X2S Traumatic subdural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, sequela S06.5X3A Traumatic subdural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounte S06.5X3D Traumatic subdural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, subsequent encounter S06.5X3S Traumatic subdural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela S06.5X4A Traumatic subdural hemorrhage with loss of consciousness of 6 hours to 24 hours, initial encounter S06.5X4D Traumatic subdural hemorrhage with loss of consciousness of 6 hours to 24 hours, subsequent encounter S06.5X4S Traumatic subdural hemorrhage with loss of consciousness of 6 hours to 24 hours, sequela S06.5X5A Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter S06.5X5D Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, subsequent encounter S06.5X5S Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela S06.5X6A Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter S06.5X6D Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter S06.5X6S Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, sequela S06.5X7A Traumatic subdural hemorrhage with loss of consciousness of any duration with death due to brain injury before regaining consciousness, initial encounter S06.5X8A Traumatic subdural hemorrhage with loss of consciousness of any duration with death due to other cause before regaining consciousness, initial encounter S06.5X9A Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter S06.5X9D Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, subsequent encounter S06.5X9S Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, sequela
S06.6X0A Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter

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S06.6X0D Traumatic subarachnoid hemorrhage without loss of consciousness, subsequent encounter S06.6X0S Traumatic subarachnoid hemorrhage without loss of consciousness, sequela S06.6X1A Traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less, initial encounter S06.6X1D Traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less, subsequent encounter S06.6X1S Traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less, sequela S06.6X2A Traumatic subarachnoid hemorrhage with loss of consciousness of 31 minutes to 59 minutes, initial encounter S06.6X2D Traumatic subarachnoid hemorrhage with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter
S06.6X2S Traumatic subarachnoid hemorrhage with loss of consciousness of 31 minutes to 59 minutes, sequela
S06.6X3A Traumatic subarachnoid hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter S06.6X3D Traumatic subarachnoid hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, subsequent encounter S06.6X3S Traumatic subarachnoid hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela S06.6X4A Traumatic subarachnoid hemorrhage with loss of consciousness of 6 hours to 24 hours, initial encounter S06.6X4D Traumatic subarachnoid hemorrhage with loss of consciousness of 6 hours to 24 hours, subsequent encounter
S06.6X4S Traumatic subarachnoid hemorrhage with loss of consciousness of 6 hours to 24 hours, sequela S06.6X5A Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter S06.6X5D Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, subsequent encounter S06.6X5S Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela S06.6X6A Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter S06.6X6D Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter S06.6X6S Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, sequela S06.6X9A Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, initial encounter S06.6X9D Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, subsequent encounter S06.6X9S Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, sequela S06.9X0A Unspecified intracranial injury without loss of consciousness, initial encounter S06.9X0D Unspecified intracranial injury without loss of consciousness, subsequent encounter S06.9X0S Unspecified intracranial injury without loss of consciousness, sequela S06.9X1A Unspecified intracranial injury with loss of consciousness of 30 minutes or less, initial encounter

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S06.9X1D Unspecified intracranial injury with loss of consciousness of 30 minutes or less, subsequent encounter S06.9X1S Unspecified intracranial injury with loss of consciousness of 30 minutes or less, sequela S06.9X2A Unspecified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, initial encounter S06.9X2D Unspecified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter S06.9X2S Unspecified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, sequela S06.9X3A Unspecified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter S06.9X3D Unspecified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, subsequent encounter S06.9X3S Unspecified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela S06.9X4A Unspecified intracranial injury with loss of consciousness of 6 hours to 24 hours, initial encounter S06.9X4D Unspecified intracranial injury with loss of consciousness of 6 hours to 24 hours, subsequent encounter S06.9X4S Unspecified intracranial injury with loss of consciousness of 6 hours to 24 hours, sequela S06.9X5A Unspecified intracranial injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter S06.9X5D Unspecified intracranial injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, subsequent encounter S06.9X5S Unspecified intracranial injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela S06.9X6A Unspecified intracranial injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter S06.9X6D Unspecified intracranial injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter S06.9X6S Unspecified intracranial injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, sequela S06.9X9A Unspecified intracranial injury with loss of consciousness of unspecified duration, initial encounter S06.9X9D Unspecified intracranial injury with loss of consciousness of unspecified duration, subsequent encounter S06.9X9S Unspecified intracranial injury with loss of consciousness of unspecified duration, sequela S09.8XXA Other Specified Injuries of Head, Initial Encounter S09.8XXD Other Specified Injuries of Head, Subsequent Encounter S09.8XXS Other Specified Injuries of Head, Sequela S09.90XA Unspecified injury of head, initial encounter S09.90XD Unspecified injury of head, subsequent encounter S09.90XS Unspecified injury of head, sequela U09.9 Post COVID-19 condition, unspecified

Description Cognitive rehabilitation is a structured set of therapeutic activities designed to retrain an individual's ability to think, use judgment, and make decisions. The focus is on improving deficits in memory, attention, perception, learning, planning, and judgment. The term cognitive rehabilitation is applied to various intervention strategies or techniques that attempt to help patients reduce, manage, or cope with cognitive

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deficits caused by brain injury. The desired outcomes are improved quality of life and function in 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 general enrichment of quality of life. Patients recuperating from traumatic brain injury have traditionally been treated with some combination of physical therapy, occupational therapy, and psychological services as indicated. Cognitive rehabilitation is considered a separate service from other rehabilitative therapies, with its own specific procedures.

Summary Description Cognitive rehabilitation is a therapeutic approach designed to improve cognitive functioning after central nervous system insult. It includes an assembly of therapy methods that retrain or alleviate problems caused by deficits in attention, visual processing, language, memory, reasoning, problem-solving, and executive functions. Cognitive rehabilitation comprises tasks to reinforce or reestablish previously learned patterns of behavior or to establish new compensatory mechanisms for impaired neurologic systems. Cognitive rehabilitation may be performed by a physician, psychologist, or a physical, occupational, or speech therapist.

Summary of Evidence For individuals who have cognitive deficits due to traumatic brain injury (TBI) who receive cognitive rehabilitation delivered by a qualified professional, the evidence includes RCTs, nonrandomized 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, nonrandomized comparison studies, case series, and systematic reviews. Relevant outcomes are functional outcomes and quality of life. A Cochrane systematic review 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 1 of 2 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 3 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 patient 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

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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, nonrandomized 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.

Additional Information Clinical input obtained in 2010 provided the strongest support for the use of cognitive rehabilitation as part of the treatment of traumatic brain injuries. As part of clinical input obtained in 2015, the American Association of Physical Medicine & Rehabilitation reasserted its position of support. Cognitive rehabilitation may be considered medically necessary for traumatic brain injury based on this input.

Policy History Date Action 12/2025 Annual policy review. Policy updated with literature review through June 4, 2025; references added. 5/2024 Policy updated with literature review through February 1, 2024; references added. Policy statements unchanged. 5/2023 Annual policy review. Minor editorial refinements to policy statements; intent unchanged. 5/2022 Annual policy review. Policy statements unchanged. 10/2021 Clarified coding information. 5/2021 Annual policy review. Minor revision to summary of 2015 Clinical Input from American Association of Physical Medicine & Rehabilitation; intent unchanged. Policy statements unchanged. 1/2021 Policy updated to include coverage for cognitive rehabilitation for cognitive impairment resulting from COVID-19 in the outpatient setting in accordance with state mandate Chapter 260 of the Acts of 2020 – Patients First Act. Clarified coding information.
Effective 1/1/2021. 5/2020 Annual policy review. Description, summary and references updated. Policy statements unchanged. 1/2020 Clarified coding information. 4/2019 Annual policy review. Description, summary and references updated. Policy statements unchanged. 5/2018 Annual policy review. New references added. Background and summary clarified. Prior Authorization Information reformatted.
1/2018 Clarified coding information. 10/2017 Clarified coding information.
4/2017 Annual policy review. New references added. 4/2016 Annual policy review. New references added. 12/2015 Annual policy review. New investigational indications described. Minor revision to medically necessary policy statement to clarify “cognitive impairment due to” traumatic brain injury. Effective 12/1/2105. 8/2014 New investigational indications described. Coding information clarified. Effective 8/1/2014. 9/2013 Annual policy review. New medically necessary indications described. Effective 9/1/2013.

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5/2013 New references from Annual policy review. 11/2011- 4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates. No changes to policy statements.
Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

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    Endnotes

    1 Massachusetts State Mandate Chapter 260 of the Acts of 2020