Cigna / ASH Medical Coverage Policies

Cigna / ASH Medical Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document may differ significantly from the standard benefit plans upon which these Cigna / ASH Medical Coverage Policies are based. In the event of a conflict, a customer's benefit plan document always supersedes the information in the Cigna / ASH Medical Coverage Policy. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document.

Determinations in each specific instance may require consideration of:

1. the terms of the applicable benefit plan document in effect on the date of service
2. any applicable laws/regulations
3. any relevant collateral source materials including Cigna-ASH Medical Coverage Policies
4. the specific facts of the particular situation

Where coverage for care or services does not depend on specific circumstances, reimbursement will only be provided if a requested service(s) is submitted in accordance with the relevant guidelines and criteria outlined in this policy, including covered diagnosis and/or procedure code(s) outlined in the Coding Information section of this policy. Reimbursement is not allowed for services when billed for conditions or diagnoses that are not covered under this policy. When billing, providers must use the most appropriate codes as of the effective date of the submission. Claims submitted for services that are not accompanied by covered code(s) under this policy will be denied as not covered.

Cigna / ASH Medical Coverage Policies relate exclusively to the administration of health benefit plans. Cigna / ASH Medical Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines. Some information in these Coverage Policies may not apply to all benefit plans administered by Cigna. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make benefit determinations. References to standard benefit plan language and benefit determinations do not apply to those clients.

GUIDELINES

Under many benefit plans, coverage for cognitive rehabilitation is subject to the terms, conditions and limitations of the applicable benefit plan’s Short Term Rehabilitative Therapy benefit and schedule of copayments. Coverage for cognitive rehabilitation therapy varies across plans. Refer to the customer’s benefit plan document for coverage details. Additionally, cognitive rehabilitation therapy coverage may be subject to state mandates.

If coverage for cognitive rehabilitation is available, the following conditions of coverage apply. Medically Necessary

Title of Cobranded Guideline (CPG 270)

An individualized program of cognitive rehabilitation is considered medically necessary for EITHER of the following:

• moderate to severe traumatic brain injury
• stroke/cerebral infarction when ALL of the following requirements are met:

• A documented cognitive impairment with related compromised functional status exists.
• Neuropsychological testing or an appropriate assessment has been performed and these test or assessment results will be used in treatment planning and directing of rehabilitation strategies.
• The individual is willing and able to actively participate in the treatment plan.
• Significant cognitive improvement with improved related functional status is expected.
• Outpatient is usually the most medically appropriate setting for cognitive rehabilitation.

Cognitive rehabilitation provided in an acute inpatient or skilled facility may be considered medically necessary if the individual independently meets coverage criteria for that level of care. Cognitive rehabilitation provided in a residential facility is considered medically necessary when the individual requires a 24-hour a day supervised environment because of cognitive impairment due to recent brain injury criteria listed above, manifested by severely impaired impulse control, judgement or executive function and cannot be safely managed in the home environment. Coverage for the residential facility placement is subject to benefit plan provisions. Continuation of cognitive rehabilitation is considered medically when both of the following criteria are met:

• The criteria listed above are met
• There is documented progress toward the quantifiable, attainable short- and long-term goals.

Not Medically Necessary

Cognitive rehabilitation to improve academic or work performance is considered not medically necessary.

Not Covered or Reimbursable

Cognitive rehabilitation for ANY other indication is not covered or reimbursable. Examples include but are not limited to:

• Cerebral palsy
• Attention deficit disorder, attention deficit hyperactivity disorder
• Pervasive developmental disorders, including autism spectrum disorders
• Learning disabilities
• Developmental delay
• Epilepsy
• Schizophrenia
• Dementia
• Mild traumatic brain injury, including concussion and post-concussion syndrome

Coma stimulation for any indication, including coma or persistent vegetative state, is considered experimental, investigational or unproven.

Title of Cobranded Guideline (CPG 270)

DESCRIPTION Cognition refers to information-processing functions carried out by the brain that include, attention, memory, executive functions (i.e., planning, problem solving, self-monitoring, self-awareness), comprehension and formation of speech, calculation ability, visual perception, and praxis skills. Cognitive processes can be conscious or unconscious and often are divided into basic level skills (e.g., attention and memory processes)

and executive functions. Cognitive function pertains to the mental processes of comprehension, judgement, memory, and reasoning, as contrasted with emotional and volitional process. Cognitive dysfunction (or cognitive impairment) can be defined as functioning below expected normative levels or loss of ability in any area of cognitive functioning. Cognitive training focuses on guided practice on a set of tasks that reflect particular cognitive functions, such as memory, attention or problem-solving. Cognitive rehabilitation is intended to improve cognitive functions and functional abilities, and increase levels of self-management and independence following neurological damage to the central nervous system. It focuses on identifying and addressing individual needs and goals, which may require strategies for taking in new information or compensatory methods such as using memory aids. Cognitive dysfunction may occur across the lifespan and may be associated with a wide range of clinical conditions. Cognitive dysfunction comes in many different forms and can come and go, remain over time, progress, be very specific or general and can range from mild to severe and affect different areas of life; like social participation, well-being, intellect, employment and functional performance. Cognitive impairments are typically categorized by severity or clinical conditions that cause the dysfunction. When rehabilitation therapy practitioners provide intervention to improve cognitive functioning (i.e., cognitive rehabilitation), the therapeutic goal is always to enhance some aspect of occupational or daily activity performance.

GENERAL BACKGROUND

Cognitive rehabilitation is a systematic, goal-oriented treatment program designed to improve cognitive functions and functional abilities, and increase levels of self-management and independence following neurological damage to the central nervous system. Although the specific tasks may be individualized to patients' needs, treatment generally emphasizes restoring lost functions; teaching compensatory strategies to circumvent impaired cognitive functions; and improving competence in performing instrumental activities of daily living (ADL) such as managing medications, using the telephone and handling finances.

The term cognitive rehabilitation may be used to describe a variety of intervention strategies or techniques that are intended to help patients reduce, manage or cope with cognitive deficits. Cognitive rehabilitation may be provided as an integrated holistic program, or as a separate component used to treat a specific cognitive defect.

Restorative and compensatory approaches are utilized in cognitive rehabilitation. The restorative approach, also referred to as direct intervention or process-specific, is based on the theory that repetitive exercise promotes recovery of damaged neural circuits and restores lost function. Restorative cognitive rehabilitation targets specific internal cognitive processes in an effort to generalize improvements to real-world settings.

Interventions typically involve exercises designed to isolate specific components of impaired cognition (e.g., selective attention, visual perception, prospective memory) and to rebuild cognition skills in a hierarchical manner. Restorative techniques include auditory, visual and verbal stimulation and practice, number manipulation, computer-assisted stimulation and practice, performance feedback, reinforcement, video feedback and meta-cognitive procedures such as behavior modification.

The compensatory approach, also referred to as the functional approach, focuses on teaching patients to employ various strategies to cope with underlying cognitive impairments and accompanying social deficits. The compensatory approach is based on the assumption that lost neurological functioning cannot be restored. The goal, therefore, is to teach strategies to circumvent impaired functioning, and encourage and reinforce intact abilities and strengths.

Compensatory techniques generally focus on activities of daily living and social interactions. Group therapies may be important to strengthen the patient’s ability to interact effectively with others. Memory impairment may be addressed by external and internal methods of rehabilitation. External aids include memory notebook systems, electronic memory devices, alarms, calendars, posted reminders, and standardized locations for necessary items. Internal aids include learning of mnemonic strategies (e.g., acronyms, peg word systems, and associated imagery).

Compensatory cognitive rehabilitation may involve modifying the physical or social environment in a way that cues a specific behavior and eliminates distraction or unwanted behavior. Although the compensatory approach to cognitive rehabilitation has been more widely accepted than the restorative approach, these techniques are not mutually exclusive. Many therapeutic programs employ both techniques.

A number of cognitive rehabilitation approaches have been proposed to address the issue of cognitive impairment such as: attention process training, integrated psychological therapy, cognitive enhancement therapy, neurocognitive enhancement therapy, and cognitive remediation therapy, the neuropsychological educational approach to remediation, errorless learning approaches, and attention shaping. Each approach shares the goal of enhancing cognitive processes or circumventing cognitive impairments in an effort to improve functional outcomes (Velligan et al., 2006). Cognitive rehabilitation may be provided by various professionals, including speech/language pathologists, occupational therapists, psychiatrists, psychologists, neuropsychologists, psychiatric nurses, cognitive remediation therapists, and physical therapists. None of these disciplines provide specific training guidelines for cognitive rehabilitation, however. Cognitive rehabilitation is usually provided on an outpatient basis, although other settings may be indicated depending on the patient’s stage of recovery and acuity level. Prior to initiation of a cognitive rehabilitation program, patients generally undergo comprehensive neuropsychological testing to evaluate and identify specific baseline deficits and impairments as well as to direct a treatment plan and develop measurable goals.

There is substantial variation in the delivery of cognitive rehabilitation with respect to essential components, program design and emphasis. Cognitive rehabilitation interventions should be structured, systematic, goal- directed (long- and short-term goals), individualized and restorative. There is no evidence in the medical literature to support a specific treatment intensity or duration for cognitive rehabilitation. Cognitive rehabilitation should be evaluated on the basis of goal achievement, including quantifiable rates of improvement in functional abilities and documented treatment outcomes. There is an expectation that some improvement can be demonstrated through documentation within two weeks. Contraindications to cognitive rehabilitation include the inability of the patient to participate in a treatment plan (i.e., orthopedic, medical, psychosocial or behavioral issues).

Cognitive rehabilitation often involves the services of a multidisciplinary team. Although cognitive rehabilitation has been proposed for numerous other conditions that may cause impaired cognitive function, there is insufficient evidence to support its use for conditions other than moderate to severe TBI or stroke.

Traumatic Brain Injury (TBI) and Stroke

A number of classification systems have been developed for assessment of neurological damage following head injury. The Glasgow Coma Scale (GCS) is generally used in the initial evaluation of the head injury. The initial GCS score helps determine prognosis and the extent of injury. GCS classifications are as follows: GCS 3–8, severe; GCS 9–13 (alternately, 9–12), moderate, and GCS 14–15 (alternately, 13–15), mild or minor. A GCS of 13-15 has traditionally been defined as a minor TBI, but many patients with a GCS of 13 have outcomes more consistent with moderate TBI, so some authorities now consider minor TBI as that producing a GCS of 14-15. Mild or minor TBI is a temporary and brief interruption of neurologic function after head trauma, and may involve a loss of consciousness. A concussion is a type of minor TBI usually caused by acceleration-deceleration or rotational injury to a freely mobile head, and is commonly associated with collision sports. Almost all-patients with minor TBI will have rapid and complete symptom resolution; with no long-term sequelae.

A small percentage of patients may report persistent symptoms (e.g., headache, sensory sensitivity, memory or concentration difficulties, irritability, sleep disturbance, depression) for extended periods after trauma. These symptoms are referred to as postconcussive syndrome (Biros and Heegaard, 2009). Other conditions contribute to the degree of severity, including posttraumatic amnesia (PTA). PTA is defined as the interval between injury and return to day-to-day memory, and can be assessed during the subacute stage of recovery by testing orientation and memory. Scores include mild (< 24 hours), moderate (24 hours to 7 days), and severe (7 days or more). The Rancho Los Amigos Cognitive Functioning Scale (RLAS) is a commonly used method to characterize and stage TBI recovery in rehabilitation settings. RLAS cognitive levels range from I, no response, to VIII, purposeful and appropriate (Evans, et al., 2007; Arciniegas, 2008, Koehler, et al., 2011). Patients with moderate or severe traumatic brain injury (TBI) may experience both cognitive and non-cognitive problems, including behavioral and emotional issues. Cognitive rehabilitation therefore is often provided as part of a comprehensive, holistic program that is focused on treatment of the cognitive, psychosocial, and behavioral issues associated with TBI. Most holistic programs include group and individual therapy in which patients are encouraged to be more aware of and accept their strengths and weaknesses, improve their social relatedness, and are provided with strategies to compensate for cognitive difficulties.

Title of Cobranded Guideline (CPG 270)

Dementia

Dementia is the development of cognitive impairments that diminish social, occupational, and intellectual abilities. It can be grouped into four major categories: degenerative (Alzheimer’s disease, Parkinson’s disease, Huntington’s disease), vascular (following stroke), infectious (HIV Type-1 associated dementia), and metabolic diseases (Wilson’s disease) (Small and Mayeux, 2005).

Schizophrenia

Schizophrenia is a severe and persistent debilitating psychiatric disorder that affects approximately 1% of the world’s population. It is characterized by disturbances in perception, cognition, mood, thought process, expression of language, and relationships with others. Symptoms can include delusions, hallucinations, and thought disorder. Neuropsychiatric changes often include impairments in information processing.

Multiple Sclerosis

Multiple sclerosis (MS) is a neurologic condition that involves a disruption of the flow of information within the brain and between the brain and the body. The progress, severity and specific symptoms of MS in any one person is variable and inconsistent. Most people with MS are diagnosed between the ages of 20 and 50, with at least two to three times more women than men being diagnosed with the disease. It involves an immune-mediated process that causes damage to the central nervous system (CNS), which includes the brain, spinal cord and optic nerves. The inflammation caused by the immune system damages the myelin, or fatty substance that surrounds and insulates the nerve fibers, the cells that produce myelin, and the nerve fibers themselves. This damage causes scarring and creates altered nerve conduction, which results in a variety of neurological symptoms. These symptoms will vary among and within individuals with MS, and can include muscle weakness, spasticity, vision problems, numbness and tingling, fatigue, cognitive and emotional changes, dizziness, and/or gait disturbances. The cause of MS is not known, but it is hypothesized to involve genetic susceptibility, abnormalities in the immune system, and environmental factors that combine to trigger the disease.

People with MS typically experience one of four disease courses.

Coma Stimulation Sensory stimulation, also referred to as coma stimulation, coma arousal therapy, multisensory stimulation and coma care, is intended to promote awakening and enhance the rehabilitative potential of coma patients. It has been proposed that with intense and repeated stimulation and precise protocols, a patient could be awakened earlier from coma and returned to a higher level of functioning. Protocols may involve stimulation of any or all of the following senses: visual, auditory, olfactory, gustatory, cutaneous, and kinesthetic.

The intensity of coma stimulation programs varies. Programs can range from one or two cycles of stimulation daily (approximately one hour each) to hourly stimulation cycles, lasting approximately 15–20 minutes, for 12–14 hours per day, six days a week. Professionals who perform the protocols include nurses, occupational therapists, physical therapists and speech-language therapists. Treatment may be delivered in the hospital, the patient’s home, or a skilled nursing facility. Due to the intensity of the program, the patient’s family may be trained in the techniques and given the primary responsibility for providing the therapy to ensure program continuation.