Note: Coverage of outpatient cognitive rehabilitation is subject to applicable benefit plan terms and limitations for physical and occupational therapy (see CPB 0250 - Occupational Therapy Services and CPB 0325 - Physical Therapy Services).  Please check benefit plan descriptions for details.

1. Aetna considers cognitive rehabilitation as adjunctive treatment of cognitive deficits (e.g., attention, language, memory, reasoning, executive functions, problem solving, and visual processing) medically necessary when all of the following are met:

   1. Neuropsychological testing has been performed and neuropsychological results will be used in treatment-planning and directing rehabilitation strategies, and
   2. The cognitive deficits have been acquired as a result of neurologic impairment due to traumatic brain injury, brain surgery, stroke, or encephalopathy, and
   3. The member has been seen and evaluated by a neuropsychiatrist or neuropsychologist, and
   4. The member is expected to make significant cognitive improvement (e.g., member is not in a vegetative or custodial state).

   Note: Cognitive rehabilitation may be performed by an occupational therapist, physical therapist, speech/language pathologist, neuropsychologist, or a physician.

   Note: According a review article on cognitive rehabilitation (Ciceron et al, 2000), rehabilitation for visuo-spatial deficits generally entails 20 1-hour sessions delivered over the course of 4 weeks.  For language and communication deficits, patients usually receive 8 hours of weekly therapy, beginning at 4 weeks post-onset and continuing up to 48 weeks post-onset.  Courses of cognitive rehabilitation substantially longer than these durations may be reviewed for medical necessity.

2. Aetna considers cognitive rehabilitation experimental and investigational for all other indications, such as the treatment of mental retardation, cerebral palsy, dementia (e.g., from Alzheimer’s disease, HIV-infection*, or Parkinson’s disease), cognitive decline in multiple sclerosis and chronic obstructive pulmonary disease, Wernicke encephalopathy, and behavioral/psychiatric disorders such as attention-deficit/hyperactivity disorder, schizophrenia, and pervasive developmental disorders including autism, as it has not been proven to be effective for these indications.

   *Note: Cognitive rehabilitation is considered medically necessary for encephalopathy due to HIV when medical necessity criteria in section I above are met.

3. Aetna considers coma stimulation, also known as the "Responsiveness Program" (cognitive remediation of comatose persons), experimental and investigational for coma and persistent vegetative state because its effectiveness has not been established.

Cognitive rehabilitation offers retraining in the ability to think, use judgment, and make decisions.  The focus is on correcting deficits in memory, concentration and attention, perception, learning, planning, sequencing, and judgment.  A neuropsychologist, aided by other specialists (e.g., occupational therapists, speech and language pathologists) may be asked to evaluate the level and kind of cognitive dysfunction following traumatic brain injury (TBI), and they may re-assess the individual over time to measure recovery.

The goals of cognitive rehabilitation are to enhance the person's capacity to process and interpret information and to improve the person's ability to function in all aspects of family and community life.  Restorative training focuses on improving a specific cognitive function, whereas compensatory training focuses on adapting to the presence of a cognitive deficit.  Compensatory approaches may have restorative effects at certain times.  Some cognitive rehabilitation programs rely on a single strategy (e.g., computer-assisted cognitive training), while others use an integrated or inter-disciplinary approach.  A single strategy program can target either an isolated cognitive function or multiple functions concurrently.

Although the interventions falling under the rubric of cognitive rehabilitation are heterogeneous, a Consensus Panel convened by the National Institutes of Health noted that these interventions share certain characteristics in that they are structured, systematic, goal-directed, and individualized and they involve learning, practice, social contact, and a relevant context.

A report of a consensus conference sponsored by the National Institute of Child Health and Human Development (NIH, 1999) concluded that, despite many descriptions of specific strategies, programs, and interventions, limited data on the effectiveness of cognitive rehabilitation programs are available because of heterogeneity of subjects, interventions, and outcomes studied.  Outcome measures present a special problem, since some studies use global "macro"-level measures (e.g., return to work), while others use "intermediate" measures (e.g., improved memory).  These studies also have been limited by small sample size, failure to control for spontaneous recovery, and the unspecified effects of social contact.  Nevertheless, a number of programs have been described and evaluated.   Despite these limitations in evidence, the consensus conference report concluded: “Evidence supports the use of certain cognitive and behavioral rehabilitation strategies for individuals with TBI [traumatic brain injury] in particular circumstances.  These interventions share certain characteristics in that they are structured, systematic, goal-directed, and individualized and they involve learning, practice, social contact, and a relevant context.”

Cognitive exercises, including computer-assisted strategies, have been used to improve specific neuropsychological processes, predominantly attention, memory, and executive skills.  A NIH Consensus Statement notes that both randomized controlled studies and case reports have documented the success of these interventions using intermediate outcome measures.  Certain studies using global outcome measures also support the use of computer-assisted exercises in cognitive rehabilitation.  An AHCPR Evidence Report/Technology Assessment concluded that there is some evidence that compensatory cognitive rehabilitation reduces anxiety and improves self-concept and relationships for people with TBI.

Compensatory devices, such as memory books and electronic paging systems, are used both to improve particular cognitive functions and to compensate for specific deficits.  Training to use these devices requires structured, sequenced, and repetitive practice.  According to a NIH Consensus Statement, the efficacy of these interventions has been demonstrated.

Interventions in cognitive rehabilitation are being developed and have only recently been subjected to the scientific inquiry.  The efficacy of cognitive rehabilitation so far has been measured by its objective influence on function and the subjective value of these changes to the individual.  An NIH Consensus Conference Report (NIH, 1999) stated: “It is important to recognize that a great deal of the scientific evidence to support the use of these approaches derives from relatively limited studies that should be replicated in larger, more definitive clinical trials.”

Amato et al (2006) stated that despite its frequency and high functional impact, very little is known about effective strategies for managing cognitive impairment in patients with multiple sclerosis (MS).  Disease-modifying drugs may prevent or reduce the progression of cognitive dysfunction by containing the development of new cerebral lesions.  Available evidence has provided inconsistent findings, with neuropsychological effects documented only in 1 trial.  Moreover, pilot studies have tested symptomatic therapies for fatigue, a frequent symptom in MS, which may share a common physiopathological substrate with cognitive dysfunction.  Small studies with amantadine, pemoline, 4-aminopyridine and 3-4 aminopyridine have provided mainly negative results.  Acetylcholinesterase inhibitors used to treat Alzheimer's disease (e.g., donepezil, rivastigmine, and galantamine) have recently been tested in other cognitive disorders, including MS.  The majority of pilot trials with acetylcholinesterase inhibitors in MS have provided promising results, and the donepezil study recently published by Krupp and colleagues represented a major development in this field.  As for non-pharmacological interventions based on cognitive rehabilitation, few studies have used an experimental approach and, in general, results have been disappointingly negative.  The authors noted that further research is clearly needed in this area.

In an evidenced-based review of cognitive rehabilitation for persons with MS, O'Brien et al (2008) concluded that cognitive rehabilitation in MS is in its relative infancy.  More methodologically rigorous research is needed to determine the effectiveness of various cognitive rehabilitation interventions. 

A Cochrane systematic evidence review by Thomas et al (2006) found "some evidence of effectiveness" of cognitive rehabilitation on cognitive outcomes in persons with MS who have cognitive impairments, although the authors found that "this was difficult to interpret because of the large number of outcome measures used".

A systematic evidence review by the BlueCross BlueShield Association Technology Evaluation Center (BCBCA, 2008) concluded that cognitive rehabilitation for traumatic brain injury does not meet the TEC criteria.  An important weakness in the literature on cognitive rehabilitation is that many clinical trials report impacts of cognitive rehabilitation on cognitive tests rather than on health outcomes.  The assessment stated that "[d]emonstration of the effectiveness of cognitive rehabilitation ... requires prospective, randomized designs that employ validated measures of health outcomes."

Coma stimulation refers to clinical intervention related to cognitive rehabilitation by attempting to improve or increase the rate of recovery and arousal of the comatose patient through increasing sensorimotor input.  It has been suggested that increasing baseline stimulation to critical brain structures, including the reticular activating system in particular, promotes arousal and recovery of these patients.  Suggestive findings of such approaches include reports of increased arousal and improvement in findings on electroencephalograms in prolonged vegetative states following dorsal column stimulation and improvement of the comatose patient's condition.  However, there are no published studies that confirm the overall efficacy of such approaches in altering the recovery patterns of comatose patients.  A Cochrane systematic evidence review (Lombardi et al, 2002) concluded that “there is no reliable evidence to support the effectiveness of multisensory programmes in patients in coma or vegetative state.”

A guideline of "Guidance on diagnosis and management of the vegetative state" from the Royal College of Physicians (2003) concluded that "there is no evidence that constant stimulation of someone who is in a vegetative state can bring about improvement in the long-term outcome."

In a randomized, controlled study, Incalzi et al (2008) examined the effects of cognitive training in patients with hypoxemic chronic obstructive pulmonary disease (COPD).  This study consisted of 105 COPD patients with at rest (n = 36) or effort (n = 69) hypoxemia and free from concurrent dementing diseases.  Neuropsychological assessment included a screening test, the Mini Mental State Examination (MMSE), and a standardized confirmatory battery of neuropsychological tests, the Mental Deterioration Battery (MDB).  After baseline assessment, patients were randomized to receive standardized multi-dimensional care (standardization of pharmacological therapy, health education, selection of inhalers according to patient's ability, respiratory rehabilitation, nutritional counseling, oxygen therapy, and control visits) with (n = 53) or without (n = 52) cognitive training aimed at stimulating attention, learning, and logical-deductive thinking.  Cognitive performance was re-assessed after 1.5, 4, and 6 months.  The analysis of variance for repeated measures (ANOVA) having the group membership (study versus control) as grouping factor was used to assess changes in cognitive performance.  Both intervention and control groups showed no significant changes in cognitive performance except for a trend toward improvement in verbal fluency and verbal memory, but cognitive intervention had no significant effect.  The authors concluded that cognitive training seems ineffective in COPD.

Brissart and colleagues (2011) noted that cognitive impairment is now well-known in MS.  However, few rehabilitation interventions are proposed or really efficient.  These investigators presented a review of cognitive rehabilitation intervention research conducted in people with MS, regarding different findings about episodic memory, working memory, attention and executive function disorders in MS.  A search of Medline (yield 20 papers) and of PsychInfo (yield 1 article), using combinations of the following terms: cognitive rehabilitation, multiple sclerosis, cognitive therapy, neuropsychological rehabilitation, in the title or in the abstract, from 1960 to March 2010, excluding animal studies.  Episodic memory rehabilitation studies appear to be promising.  Programs on working memory, attention and executive functions are in the very early phases.  The authors concluded that results are encouraging and allow specific recommendations for future research regarding (i) inclusion criteria, often not defined, (ii) a specific baseline adapted to the program of rehabilitation, (iii) a control measure regarding program efficiency, and (iv) a role for the psychologist (presence and advice during the program).

Note: Cognitive rehabilitation should not be confused with cognitive behavior therapy.  Cognitive behavior therapy (also known as cognitive therapy) is a form of psychotherapy that emphasizes the role of thought patterns in moods and behaviors.

Georgiopoulos et al (2010) performed a systematic review of the proposed medical or surgical treatments in patients in chronic vegetative state (VS) or minimally conscious state (MCS), as well as of their mechanisms of action and limitations.  For this review, these researchers have agreed to include patients in VS or MCS having persisted for over 6 months in post-traumatic cases, and over 3 months in non-traumatic cases, before the time of intervention.  Searches were independently conducted by 2 investigators between May 2009 and September 2009 in the following databases: Medline, Web of Science and the Cochrane Library.  The electronic search was complemented by cross-checking the references of all relevant articles.  Overall, a total of 16 papers were eligible for this systematic review.  According to the 16 eligible studies, medical management by dopaminergic agents (levodopa, amantadine), zolpidem and median nerve stimulation, or surgical management by deep brain stimulation, extra-dural cortical stimulation, spinal cord stimulation as well as intra-thecal baclofen have shown to improve the level of consciousness in certain cases.  The authors concluded that the treatments proposed for disorders of consciousness have not yet gained the level of “evidence-based treatments”.  Moreover, the studies to-date had led to inconclusiveness.  They stated that the published therapeutic responses must be substantiated by further clinical studies of sound methodology.

The American Academy of Neurology’s practice parameters on “Assessment and management of patients in the persistent vegetative state” (AAN, 2006) did not mention the use of coma stimulation as a treatment modality.  Also, the American Occupational Therapy Association’s practice guideline on “Adults with traumatic brain injury” (Golisz, 2009) made no recommendation regarding the use of sensory stimulation or coma arousal programs.  Furthermore, the National Institute of Neurological Disorders and Stroke’s “Coma information page” (NINDS, 2012) did not mention the use of coma stimulation as a therapeutic option.

Appendix

Aetna requires that cognitive therapy and other rehabilitation be provided in accordance with an ongoing, written plan of care created by the therapist.  The purpose of the written plan of care is to assist in determining medical necessity and should include the following:

The written plan of care should be sufficient to determine the medical necessity of treatment, including:

• The diagnosis along with the date of onset of the condition;
• A reasonable estimate of when the goals will be reached;
• Long-term and short-term goals that are specific, quantitative and objective;
• Cognitive therapy evaluation;
• The frequency and duration of treatment; and
• The specific techniques to be used in treatment.

The plan of care should be ongoing, (i.e., updated as the patient's condition changes), and treatment should demonstrate reasonable expectation of improvement.  Cognitive therapy is considered medically necessary only if there is a reasonable expectation that cognitive therapy will achieve measurable improvement in the patient's condition in a reasonable and predictable period of time.

The therapist should re-evaluate the patient regularly (this is typically done on a monthly basis) and document the progress toward the goals of cognitive therapy in the patient's clinical record.  The treatment goals and subsequent documentation of treatment results should specifically demonstrate that cognitive therapy services are contributing to such improvement.