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Blue Cross Sets New Criteria for Brain Injury Rehabilitation Reimbursement

Blue_cross Obtaining reimbursement from a medical plan for brain injury rehabilitation also referred to as cognitive rehabilitation is one of the most frustrating experiences that a family or their brain injury lawyer must deal with following brain trauma.

Now Blue Cross of Iowa has issued new guidelines authorizing services for cognitive rehabilitation.  Most importantly the guidelines recognize both the validity of cognitive therapy as a valid treatment for brain damage and that these services can be performed by physicians, psychologists as well as by physical, occupational and speech therapists. 

While I find problems with their definition of "medically necessary" especially with the requirement that their is an expectation of "measurable improvements  in a reasonable and predictable period of time" since the rate of improvement and progress following brain injury rehabilitation can take many months or even years with improvements coming at unpredictable times, it is a start.  The difficulty with definitions such as used by blue cross is the attempt to measure improvement following brain damage in the same way that improvements are measured following rehab for a broken hip.  Unfortunately, that's just not the way the brain heals. 

Here are the full blue cross cognitive rehabilitation guidelines:

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 a variety of intervention strategies or techniques that attempt to help patients reduce, manage or cope with cognitive deficits.  The desired outcome of cognitive rehabilitation is an improved quality of life or an improved ability to function in home and community life.  Cognitive rehabilitation may be performed by a physician, psychologist, or a physical, occupational or speech therapist.

Policy:

Cognitive rehabilitation may be considered medically necessary following a stroke or traumatic brain injury when the plan of care documents specific diagnosis-related goals for a patient who has a reasonable expectation of achieving measurable improvements in a reasonable and predictable period of time.
Cognitive rehabilitation is not a covered benefit if it is considered not medically necessary because it has become a maintenance program. A maintenance program consists of activities that preserve the patient's present level of function and prevents regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur.

You can go to their site and read their references by clicking here .

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