Description

Cognitive rehabilitation is a multidisciplinary treatment program designed to improve acquired neurocognitive impairment and disability by reinforcing, strengthening, or re-establishing previously learned patterns of behavior; or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.³

There are two approaches to cognitive rehabilitation:

• Compensatory (adaptive) cognitive rehabilitation uses adaptive devices and strategies along with modification of the environment to provide alternative approaches for carrying out activities despite residual cognitive deficits.
• Restorative or remedial cognitive rehabilitation utilizes a variety of repetitive exercises to improve, strengthen or normalize specific impaired cognitive functions.

Coma stimulation, also referred to as coma arousal therapy or sensory stimulation, is purported to encourage awakening in a comatose individual by increasing environmental stimulation to the senses using a variety of stimuli. (Refer to Coverage Limitations Section)

For information regarding application-based games (computer training programs) for use with home computer, smart phone or tablet, please refer to Digital Therapeutics Medical Coverage Policy.

Coverage Determination

Services provided by a psychiatrist, psychologist or other behavioral health professionals are subject to the provisions of the applicable behavioral health benefit.

Refer to specific certificate language regarding cognitive rehabilitation. Most certificates limit the duration or number of visits.

Any state mandates for cognitive rehabilitation take precedence over this medical coverage policy.

Humana members may be eligible under the Plan for cognitive rehabilitation for cognitive deficits that occur as a result of ANY of the following:

• Moderate to severe post-traumatic brain injury (TBI); OR
• Stroke;

AND when the following criteria are met:

1. Individual has the ability to actively participate in a cognitive rehabilitation program (eg, not comatose or in a vegetative state); AND
2. Potential for improvement exists; AND
3. Provided by a licensed healthcare professional (eg, neuropsychologist, psychiatrist, physician, psychologist, speech/language pathologist, physical or occupational therapist)

Cognitive rehabilitation is subject to review every 30 days to determine demonstrable improvement (eg, documented progress toward short- and long-term goals).

When cognitive rehabilitation is performed in the inpatient setting, it is subject to meeting acute inpatient rehabilitation criteria. When performed in the outpatient setting, it is subject to certificate limitations for physical medicine and/or rehabilitative services.

Coverage Limitations

Humana members may NOT be eligible under the Plan for cognitive rehabilitation for maintenance care, which occurs when therapeutic goals of the treatment program are achieved or when no further significant progress is made or reasonably seen as occurring as this is generally excluded in the certificate.

In the absence of a certificate exclusion for maintenance care, it would be considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for cognitive rehabilitation for any indications other than those listed above including, but may not be limited to, the following:

• Attention deficit hyperactivity disorder (ADD/ADHD); OR
• Autism spectrum disorders (ASD); OR
• Dementia (eg, Alzheimer’s); OR
• Learning disabilities; OR
• Mild TBI, including sports-related concussion

Cognitive Rehabilitation Effective Date: 04/27/2023

Revision Date: 04/27/2023

Review Date: 04/27/2023

Policy Number: HUM-0426-020

Page: 4 of 8

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

This is considered experimental/investigational as it is not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for coma stimulation for any indication. This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Background

Additional information about brain injury, coma, neurological conditions or stroke may be found from the following websites:

• American Stroke Association
• National Institute of Neurological Disorders and Stroke
• National Library of Medicine

Medical Alternatives

Alternatives to cognitive rehabilitation include, but may not be limited to, the following:

• Physical therapy/occupational therapy (please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy)
• Psychotherapy
• Speech therapy (please refer to Speech Therapy Medical Coverage Policy)

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Humana may offer a disease management program for this condition. The member may call the number on his/her identification card to ask about our programs to help manage his/her care.

Cognitive Rehabilitation Effective Date: 04/27/2023

Revision Date: 04/27/2023

Review Date: 04/27/2023

Policy Number: HUM-0426-020

Page: 5 of 8

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.