Cognitive Rehabilitation Denial Overturned An external review board has overturned a Blue Cross & Blue Shield of Mississippi denial of cognitive rehabilitative therapy for a man who suffered a stroke, calling the services “medically necessary.” The insurer covers cognitive rehabilitation for traumatic brain injury, but denied similar coverage for rehabilitation following a stroke or ... On the Pulse
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On the Pulse  |   August 01, 2012
Cognitive Rehabilitation Denial Overturned
Author Notes
  • Janet McCarty, MEd, CCC-SLP, private health plans advisor, can be reached at jmccarty@asha.org.
    Janet McCarty, MEd, CCC-SLP, private health plans advisor, can be reached at jmccarty@asha.org.×
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Attention, Memory & Executive Functions / On the Pulse
On the Pulse   |   August 01, 2012
Cognitive Rehabilitation Denial Overturned
The ASHA Leader, August 2012, Vol. 17, 11. doi:10.1044/leader.OTP.17102012.11
The ASHA Leader, August 2012, Vol. 17, 11. doi:10.1044/leader.OTP.17102012.11
An external review board has overturned a Blue Cross & Blue Shield of Mississippi denial of cognitive rehabilitative therapy for a man who suffered a stroke, calling the services “medically necessary.”
The insurer covers cognitive rehabilitation for traumatic brain injury, but denied similar coverage for rehabilitation following a stroke or aneurysm. Trae Sims, an attorney for the patient, indicated that the independent external review board’s decision may be the first of its kind in Mississippi, and that the wording of the ruling—“cognitive rehabilitation is not experimental or investigational in nature. The use of cognitive rehabilitation is clearly medically necessary and is consistent with good medical practice for this diagnosis”—expands the possibility for treatment for others with similar conditions.
James Butler suffered a series of strokes that left him with right hemiparesis as well as speech and cognitive deficits that limited his ability to function and compromised his safety. Butler’s wife, Mary Hawkins Butler—the mayor of Madison, Mississippi—recognized the need for continued treatment after her husband’s brief inpatient and outpatient rehabilitation stays. She had Butler admitted to a residential rehabilitation facility. Hawkins Butler reported that her husband progressed from needing round-the-clock care to showing noticeable improvements in “speech and cognition” that enabled him to lead a more independent life.
Once Butler’s functional status improved, the next step was to appeal the denied Blue Cross & Blue Shield of Mississippi claims for the cognitive rehabilitation that had significantly improved Butler’s functional abilities. Hawkins Butler pursued a lengthy appeal process because she wanted her husband’s success story to help correct what she refers to as the “injustices” the insurer was perpetrating on other stroke patients. With Sims’ assistance, the family filed for an independent review of the case.
Evidence submitted by the family included a March 1, 2006, letter from ASHA to Blue Cross Blue Shield Association that outlined data from ASHA’s National Outcomes Measurement System and other supports for cognitive rehabilitation. Documentation also referenced a literature review on patients who receive cognitive rehabilitation that concluded “there is sufficient information to support evidence protocols and implement empirically-supported treatments for cognitive disability after traumatic brain injury and stroke” (Cicerone et al., 2011).
An independent physician—a specialist in physical medicine and rehabilitation—reviewed the case and concluded that “cognitive rehabilitation meets the health plan’s definition of medical necessity” and the plan’s basis for denial was not supported.
ASHA is active in efforts to improve coverage of cognitive rehabilitation by all payers, including Blue Cross & Blue Shield plans. The Blue Cross Blue Shield Association recently removed from its public website a 2008 report that deemed cognitive rehabilitation “investigational” (The ASHA Leader, Nov. 22, 2011).
This action, coupled with the lack of a replacement, may signal a change in the policy on coverage of cognitive rehabilitation services for the national group, whose companies provide health care coverage to 98 million people in America.
Sources
Cicerone, K. D., Langenbahn, D. M., Braden, C., Malec, J. F., Kalmar, K., Fraas, M., … Ashman, T. (2011). Evidence-based cognitive rehabilitation: Updated review of the literature from 2003 through 2008. Archives of Physical Medicine & Rehabilitation, 92(4), 519–530. [Article]
Cicerone, K. D., Langenbahn, D. M., Braden, C., Malec, J. F., Kalmar, K., Fraas, M., … Ashman, T. (2011). Evidence-based cognitive rehabilitation: Updated review of the literature from 2003 through 2008. Archives of Physical Medicine & Rehabilitation, 92(4), 519–530. [Article] ×
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August 2012
Volume 17, Issue 10