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MP 8.03.10 Cognitive Rehabilitation

Medical Policy    
Section
Therapy
 
Original Policy Date
11/1/97
Last Review Status/Date
Reviewed with literature search/2:2012
Issue
2:2012
  Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


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 consists of tasks designed to reinforce or re-establish previously learned patterns of behavior or to establish new compensatory mechanisms for impaired neurological systems. Cognitive rehabilitation may be performed by a physician, psychologist, or a physical, occupational, or speech therapist.

Cognitive rehabilitation must be distinguished from occupational therapy (CPT codes 97535–97537); occupational therapy describes rehabilitation that is directed at specific environments (i.e., home or work). In contrast, cognitive rehabilitation consists of tasks designed to develop the memory, language, and reasoning skills that can then be applied to specific environments, as described by the occupational therapy codes.

Sensory integrative therapy may be considered a component of cognitive rehabilitation. However, sensory integration therapy is considered separately in policy No. 8.03.13.


Policy

Cognitive rehabilitation (as a distinct and definable component of the rehabilitation process) may be considered medically necessary in the rehabilitation of patients with traumatic brain injury.

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, post-encephalitic or post-encephalopathy patients, and the aging population, including Alzheimer’s patients.


Policy Guidelines

For services to be considered medically necessary, they must be provided by a qualified licensed professional and must be prescribed by the attending physician as part of the written care plan. In addition, there must be a potential for improvement (based on pre-injury function), and patients must be able to actively participate in the program. (Active participation requires sufficient cognitive function to understand and participate in the program, as well as adequate language expression and comprehension, i.e., participants should not have severe aphasia.) Ongoing services are considered necessary only when there is demonstrated continued objective improvement in function.

Duration and intensity of cognitive rehabilitation therapy programs vary. One approach for comprehensive cognitive rehabilitation is a 16-week outpatient program consisting of 5 hours of therapy a day, 4 days a week. In this approach, cognitive group treatment occurs for three 2-hour sessions each week and three 1-hour individual sessions (total of 9 hours per week). (In one study, control patients received 12 to 24 hours per week of comprehensive standard outpatient rehabilitation services.) Cognitive rehabilitation programs for specific defects, e.g., memory training, are less intensive and generally have 1 or 2 sessions (30 or 60 minutes) per week for 4 to 10 weeks.

Cognitive rehabilitation is identified by the following CPT code:

97532: Development of cognitive skills to improve attention, memory, problem solving (include compensatory training), direct (one on one) patient contact by the provider, each 15 minutes.

Sensory integration therapy, explicitly identified by CPT code 97533, is addressed separately in policy No. 8.03.13.


Benefit Application
BlueCard/National Account Issues

Cognitive rehabilitation may be managed through a case management approach.

Contractual limitations on rehabilitative services may apply.


Rationale

This policy was originally created in 1997 and has been updated periodically with literature review. The most recent update with literature review covered the period of January 2012 through January 2013.

This policy was originally based on a 1997 TEC Assessment. (1) The Assessment addressed a broad range of patient indications resulting from neurologic insults, including traumatic brain injury, stroke, post-encephalopathy, and aging (including Alzheimer’s disease). Eighteen controlled trials were reviewed, primarily focusing on stroke and traumatic brain injury. No controlled trials were available that specifically addressed the remaining patient indications. No clear answer regarding the efficacy of cognitive rehabilitation emerged from the Assessment. The evidence was conflicting either because of study design, low power to detect differences, or variation in treatment. The Assessment concluded that data were inadequate in the published peer-reviewed literature to validate the effectiveness of cognitive rehabilitation as either an isolated component or one component of a multimodal rehabilitation program.

Traumatic Brain Injury

A 2008 TEC Assessment was completed on cognitive rehabilitation in traumatic brain injury. (2) The objective of this Assessment was to determine whether there is adequate evidence to demonstrate that cognitive rehabilitation results in improved health outcomes. In this TEC Assessment, cognitive test performance was not considered a health outcome. Results of instruments assessing daily functioning or quality of life were considered health outcomes.

For the Assessment’s main evidence review, randomized, controlled trials (RCTs) of cognitive rehabilitation were selected. A nonrandomized study of a comprehensive holistic program of cognitive rehabilitation was also included. Two studies of comprehensive holistic cognitive rehabilitation were reviewed. The one randomized study found no differences in the outcomes of return to work, fitness for military duty, quality of life, and measures of cognitive and psychiatric function at 1 year. (3) Rates of returning to work were greater than 90% for both the intervention and control groups, raising the question whether the subjects included in the study were not severely injured enough to be able to demonstrate an effect of rehabilitation. The other study of comprehensive rehabilitation was nonrandomized. (4) The intervention group showed greater improvements in functioning, as assessed by a questionnaire that evaluated community integration, home integration, and productivity assessed on completion of the intervention. However, there were many differences in baseline characteristics between intervention and control groups, particularly regarding the time since injury. Patients were not followed up beyond completion of the intervention program.

Eleven RCTs of cognitive rehabilitation for specific cognitive defects showed inconsistent support for cognitive rehabilitation. (Please refer to the 2008 TEC Assessment for further details of these studies, including the citations.) Out of the 11 studies, 8 reported on health outcomes. Three of the studies showed statistically significant differences between intervention groups and control groups on one outcome. However, 2 of the studies were extremely small. The findings were not consistent across other outcomes measured in the studies, and in one study, significant findings after the intervention were no longer present at 6 months of follow-up. All 11 studies also reported outcomes of various cognitive tests. These were not considered to be valid outcomes for the purposes of assessing health benefit. Evaluation of these studies assessing cognitive test outcomes was plagued by numerous methodologic problems, such as small sample size, lack of long-term follow-up, minimal interventions, and multiple outcomes. Seven of the studies reported at least one outcome showing that cognitive rehabilitation was associated with better performance on a specific cognitive test. Of these positive studies, 2 of them had no follow-up beyond the time of treatment, and 2 had sample sizes smaller than 20. In only 1 study was there consistency across several cognitive test scores showing better performance with cognitive rehabilitation.

In summary, the randomized trials reviewed in the TEC Assessment did not show strong evidence for efficacy in the treatment of traumatic brain injury. Many of the clinical trials of specific cognitive rehabilitation interventions evaluated cognitive tests rather than health outcomes.

Since the TEC Assessment was completed, an additional RCT was published in 2008 comparing a comprehensive program of neuropsychologic rehabilitation to standard rehabilitation. (5) This study was intended to be a more rigorous evaluation of the nonrandomized study (4) reviewed in the 2008 TEC Assessment. Sixty-eight patients were randomized to the 2 intervention groups. The principal outcomes measured were the Community Integration Questionnaire (CIQ) and the Perceived Quality of Life scale (PQOL). Effectiveness of the intervention was evaluated by an interaction between intervention and pre- to post-treatment. Such an interaction was significant for the CIQ (p=0.042) and the PQOL (p=0.049) but not for any of the secondary neuropsychologic outcomes. It should be noted that there was a much smaller increment of improvement in the CIQ (from 11.2 to 12.9) then was observed in the prior nonrandomized trial (11.6 to 16.1). The proportion of patients having a clinically significant improvement in CIQ (4.2 points) is not reported but is likely to be smaller than the 52% reported in the prior non-randomized study. Follow-up assessments were also done at 6 months after treatment, but these were not subjected to formal statistical analysis. It appears that the standard treatment group had further improvements in the CIQ such that their mean follow-up CIQ score is very similar to the intervention group (12.9 versus 13.2) and likely to be nonsignificant. For the PQOL, it appears that the differences observed at the end of treatment were maintained or magnified somewhat by 6 months. This randomized trial, thus, has mixed findings of efficacy of comprehensive neuropsychologic rehabilitation for traumatic brain injury.

Dementia, including Alzheimer’s Disease

The use of cognitive training or rehabilitation in Alzheimer’s disease and vascular dementia was evaluated in a 2003 Cochrane review. (6) It found 6 randomized, controlled trials (RCTs) on cognitive training that met study selection criteria, none of which reported any statistically significant between-group differences on any outcomes. A randomized trial was published in 2003 by Spector et al. (7) A total of 115 subjects were randomized to receive a cognitive stimulation program or to a control group. The intervention program ran for 7 weeks, and patients were only evaluated at this time point. The treatment group had significantly higher scores on the principal outcome, the mini-mental status exam (MMSE), with a group difference of 1.14 points. Differences were also significant for the secondary outcomes, a quality-of-life score for Alzheimer’s disease and an Alzheimer’s disease assessment scale. The study did not assess any outcomes beyond the 7-week period of treatment, and the authors speculate that the intervention would need to be continued on a regular basis beyond 7 weeks. The results of this trial are not definitive in determining whether cognitive rehabilitation therapy is effective among patients with dementia. Limitations of the existing literature were discussed in a 2006 meta-analysis on cognitive training in Alzheimer’s disease. (8) One study reported on patients who had not yet developed dementia. A study of 2,832 seniors living independently with good functional and cognitive status were randomized to 1 of 3 training groups (memory, reasoning, speed of processing) or a no-contact control group. (9) While selected cognitive functioning measures showed immediate improvements, no significant improvements were found on everyday functioning measures at 2 years. A controlled study reported on 25 mildly impaired patients on cholinesterase inhibitors. (10) Patients were assigned to either cognitive rehabilitation or equivalent therapist contact in a mental stimulation program. Beneficial effects were observed for cognitive rehabilitation on tasks that duplicated those used in training, although generalized functional improvements were not reported. Moreover, the differences between the 2 interventions are not completely clear in that both used methodologies considered to be cognitive rehabilitation. An additional randomized study of 54 patients evaluated the combined effect of a cognitive-communication therapy plus an acetylcholinesterase inhibitor as compared to drug treatment alone. (11) A positive effect for the drug plus cognitive rehabilitation group was found in the areas of discourse abilities, functional abilities, emotional symptoms, and overall global performance. Beneficial effects were reported up to 10 months after active intervention. While the available evidence on cognitive rehabilitation for Alzheimer’s disease and related dementias is inadequate to permit conclusions, this last study provides some encouraging evidence. Additional collaborative data are needed to form conclusions about the effectiveness of a combined treatment of cognitive rehabilitation and acetylcholinesterase inhibitors in patients with Alzheimer’s disease. The use of cognition-based interventions for healthy older people and people with mild cognitive impairment was the subject of a Cochrane systematic review published in 2011. (12) The review concluded there was little evidence on the effectiveness and specificity of such interventions, as improvements observed were similar to effects seen with active control interventions.

Kurz et al. published an RCT in 2011 for patients with Alzheimer’s disease and early dementia. (13) The population consisted of 201 patients with clinical evidence and dementia and a MMSE score of at least 21/30 who were randomized to a 12-week cognitive rehabilitation program. There were baseline imbalances among the groups, with the intervention group having a lower mean age and higher scores on measures of functional status and quality of life. Outcomes were assessed at 3 months and 9 months following intervention and included a range of measures of functional status, quality of life, cognition, and caregiver burden. There were no between group differences on any of the outcome measures. There were also no group differences on subgroup analyses by age, gender, educational level, or baseline cognitive ability, except that depression scores improved significantly for females, but not males, in the intervention group.

Post-encephalopathy

Recent reports on cognitive rehabilitation and encephalopathy were limited to 2 small, uncontrolled series. While both series reported favorable results with rehabilitation, the data are inadequate to change the conclusions of the earlier TEC Assessment. (14, 15)

Stroke

The effectiveness of cognitive rehabilitation for stroke was assessed in 3 Cochrane reviews that separately evaluated memory deficits, attention deficits, and spatial neglect. The most recent updates of these reviews made the following conclusions. (16-18)

  • Controlled studies investigating the effectiveness of cognitive rehabilitation in improving memory deficits due to stroke were limited to 2 trials of 18 patients. Outcomes showed that memory strategy training had no significant effect on memory impairment or subjective memory complaints.
  • Attention deficits following stroke were evaluated in 2 controlled trials involving 56 patients. The review concluded that there is some indication that training improves alertness and sustained attention but no evidence exists to support or refute the use of cognitive rehabilitation for attention deficits to improve functional independence after stroke.
  • The Cochrane review of cognitive rehabilitation for spatial neglect included 12 studies involving 306 subjects. Reported outcome measures varied widely between studies. The reviewers concluded that there is some evidence that cognitive rehabilitation for spatial neglect improves performance on some impairment tests, but its effect on disability is unclear. Further well-designed randomized controlled trials are warranted as well as basic research to develop valid outcome measures.

A second review on the rehabilitative management of post-stroke visuospatial inattention also concluded that the long-term impact of visual scanning and perceptual retraining techniques on overall recovery and functional outcome was unclear. (19)

Clinical Input Received through Physician Specialty Societies and Academic Medical Centers

In response to requests, input was received from 2 physician specialty societies and 5 academic medical centers while this policy was under review in 2009 and 2010. While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted. The strongest support was for use of cognitive rehabilitation as part of the treatment of those with traumatic brain injuries. The level of support varied for other diagnoses such as use in post-stroke patients.

Summary

For patients with traumatic brain injury, there are numerous RCTs evaluating the efficacy of cognitive rehabilitation. However, these trials have methodologic limitations and report mixed results, indicating that there is not a uniform or consistent evidence base supporting the efficacy of this technique. Based on review of the published trials, together with the clinical input, and consideration of the limited alternative treatments, use of cognitive rehabilitation as a distinct and definable component of the rehabilitation process may be considered medically necessary as part of the treatment of those with traumatic brain injury.

For other indications, the evidence on cognitive rehabilitation is insufficient to permit conclusions, and the clinical input was not uniform in favor of cognitive rehab. Therefore, use of cognitive impairment in disease states other than traumatic brain injury is considered investigational.

Practice Guidelines and Position Statements

The Institute of Medicine published a report in October 2011 titled “Cognitive Rehabilitation Therapy for Traumatic Brain Injury” (20) that included a comprehensive review of the literature and recommendations. The report concluded that “…current evidence provides limited support for the efficacy of CRT 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 in order to improve the evidence base for this treatment. They also recommended that future studies are needed that have larger sample sizes and include a more comprehensive set of clinical variables and outcome measures.

The VA/Department of Veterans Affairs (DoD) published guidelines on the treatment of concussion/mild traumatic brain injury in 2009. (21) These guidelines address cognitive rehab in the setting of persistent symptoms. The guidelines state:

Individuals who present with memory, attention, and/or executive function problems which did not respond to initial treatment (e.g., reassurance, sleep education, or pain management) may be considered for referral to cognitive rehabilitation therapists with expertise in TBI rehabilitation (e.g., speech and language pathology, neuropsychology, or occupational therapy) for compensatory training [Strength of Recommendation = C]; and/or instruction and practice on use of external memory aids such as a personal digital assistant (PDA) [Strength of Recommendation = C].

Medicare National Coverage

None

References:

 

 

  1. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Cognitive rehabilitation. TEC Assessments 1997; Volume 12, Tab 6.
  2. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Cognitive rehabilitation for traumatic brain injury in adults. TEC Assessment 2008; Volume 23, Tab 3.
  3. Salazar AM, Warden DL, Schwab K et al. Cognitive rehabilitation for traumatic brain injury: a randomized trial. JAMA 2000; 283(23):3075-81.
  4. Cicerone KD, Mott T, Azulay J et al. Community integration and satisfaction with functioning after intensive cognitive rehabilitation for traumatic brain injury. Arch Phys Med Rehabil 2004; 85(6):943-50.
  5. Cicerone KD, Mott T, Azulay J et al. A randomized controlled trial of holistic neuropsychologic rehabilitation after traumatic brain injury. Arch Phys Med Rehabil 2008; 89(12):2239-49.
  6. Clare L, Woods RT, Moniz Cook ED et al. Cognitive rehabilitation and cognitive training for early-stage Alzheimer’s disease and vascular dementia. (Cochrane Review). Cochrane Database Syst Rev 2003; (4):CD003260.
  7. Spector A, Thorgrimsen L, Woods B et al. Efficacy of an evidence-based cognitive stimulation therapy programme for people with dementia: randomised controlled trial. Br J Psychiatry 2003; 183(3):248-54.
  8. Sitzer DI, Twamley EW, Jeste DV. Cognitive training in Alzheimer’s disease: A meta-analysis of the literature. Acta Psychiatr Scand 2006; 114(2):75-90.
  9. Ball K, Berch DB, Helmers KF et al. Effects of cognitive training interventions with older adults: a randomized controlled trial. JAMA 2002; 288(18):2271-81.
  10. Loewenstein DA, Acevedo A, Czaja SJ et al. Cognitive rehabilitation of mildly impaired Alzheimer disease patients on cholinesterase inhibitors. Am J Geriatr Psychiatry 2004; 12(4):395-402.
  11. Chapman SB, Weiner MF, Rackley A et al. Effects of cognitive-communication stimulation for Alzheimer’s disease patients treated with donepezil. J Speech Lang Hear Res 2004; 47(5):1149-63.
  12. Martin M, Altgassen AM, Cameron MH, Zehnder F. Cognition-based interventions for healthy older people and people with mild cognitive impairment. Cochrane Database Syst Rev 2011; (1):CD006220.
  13. Kurz A, Thone-Otto A, Cramer B et al. CORDIAL: Cognitive rehabilitation and cognitive-behavioral treatment for early dementia in Alzheimer disease. Alzheimer Dis Assoc Disord 2011 [Epub ahead of print].
  14. Lindgren M, Hagstadius S, Abjornsson G et al. Neuropsychological rehabilitation of patients with organic solvent-induced chronic toxic encephalopathy. A pilot study. Neuropsychological Rehabilitation 1997; 7(1):1-22.
  15. Schmidt JG, Drew-Cates J, Dombovy ML. Anoxic encephalopathy: outcome after inpatient rehabilitation. J Neurologic Rehabilitation 1997; 11(3):189-95.
  16. Nair RD, Lincoln NB. Cognitive rehabilitation for memory deficits following stroke. Cochrane Database Syst Rev 2007; (3):CD00293.
  17. Lincoln NB, Majid MJ, Weyman N. Cognitive rehabilitation for attention deficits following stroke. Cochrane Database Syst Rev 2000; (4):CD002842.
  18. Bowen A, Lincoln NB.. Cognitive rehabilitation for spatial neglect following stroke. Cochrane Database Syst Rev 2007; (2):CD003586.
  19. Diamond PT. Rehabilitative management of post-stroke visuospatial inattention. Disabil Rehabil 2001; 23(10):407-12.
  20. Institute of Medicine, National Academies Press. Cognitive rehabilitation therapy for traumatic brain injury. 2011, October. Available online at: http://iom.edu/Reports/2011/Cognitive-Rehabilitation-Therapy-for-Traumatic-Brain-Injury-Evaluating-the-Evidence.aspx . Last accessed January 2012.
  21. Department of Veterans Affairs, Department of Defense. VA/DoD clinical practice guideline for management of concussion/mild traumatic brain injury. Washington (DC): Department of Veteran Affairs, Department of Defense; 2009.

 

Codes

Number

Description

CPT  97532  Development of cognitive skills to improve attention, memory, problem solving (include compensatory training), direct (one on one) patient contact by the provider, each 15 minutes 
ICD-9 Procedure  93.89  Rehabilitation, not elsewhere classified 
ICD-9 Diagnosis  850–854  Intracranial injury 
  331  Alzheimer’s disease 
HCPCS  No Code   
ICD-10-CM (effective 10/1/14) S06.0-S06.9x9- Traumatic brain injury, code range
ICD-10-PCS (effective 10/01/14)   ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for this therapy.
  F06ZDZZ Physical Rehabilitation Speech
  F07Z4ZZ Physical Rehabilitation Motor Treatment
  F08Z6ZZ Physical Rehabilitation – Activities of Daily Living Treatment
Type of Service  Therapy 
Place of Service  Inpatient 
Outpatient
 


Index

Cognitive Rehabilitation
Rehabilitation, Cognitive  


Policy History

Date Action Reason
11/01/97 Add to Therapy Section New policy
10/15/00 Replace policy New CPT codes
12/18/02 Replace policy Policy updated; no change in policy statement. Rationale expanded, new references provided
11/9/2004 Replace policy Policy updated; no change in policy statement. New references provided
12/14/05 Replace policy Policy updated; no change in policy statement. New references provided
12/12/06 Replace policy Policy updated with literature review; no change in policy statement. Reference numbers 25-27 added
04/09/08 Replace policy  Policy updated with 2008 TEC Assessment and with literature search in March 2008; no change in policy statement. Rationale section rewritten. Reference numbers 2, 3, 4, and 16 added.
05/13/10 Replace policy Policy updated with literature search; references 5, 11, and 19 added. Clinical input reviewed. Policy statement changed to medically necessary for traumatic brain injury when specific conditions are met.
2/09/12 Replace policy Policy updated with literature review. Rationale rewritten, references 13, 20, 21 added. No change to policy statement.
03/14/13 Replace policy Policy updated with literature review through January 2013, no new references added. Policy statement unchanged.