Cognitive Rehabilitation

Number 8.03.504

Effective Date September 9, 2013

Revision Date(s) 09/09/13, 05/13/13; 04/10/12; 02/08/11; 02/09/10; 05/13/08; 03/13/07; 03/14/06; 03/08/05; 01/01/04; 05/13/03; 01/23/01; 12/21/00; 11/03/98

Replaces 8.03.10


Cognitive rehabilitation as a distinct and definable component of a comprehensive rehabilitation program may be considered medically necessary in the rehabilitation for patients after an insult to the brain such as a traumatic brain injury or cerebrovascular accident (also known as CVA, stroke or brain attack).

Cognitive rehabilitation as a distinct and definable component of a comprehensive rehabilitation program is investigational for all other applications, including but not limited to: post-encephalitic or post-encephalopathy patients; and the aging population, including patients with Alzheimer's disease.

Related Policies


Sensory Integration Therapy


Occupational Therapy

Policy Guidelines

Cognitive rehabilitation must meet ALL of the following criteria:

  • Services are for the patient with a documented physical impairment, functional limitation or disability due to traumatic brain injury or cerebrovascular accident. AND
  • The rehabilitation plan includes realistic individual goals that are clearly identified and are likely to be met within a predictable timeframe AND
  • There is proof the patient is able to actively participate in the rehabilitation program AND
  • Services are delivered by qualified providers performing within the scope of their licensure or practice

A comprehensive rehabilitation program encompasses a multidisciplinary approach from several different treatment specialties, such as occupational therapy, speech therapy, physical therapy, and other support services as indicated for the restorative correction of the illness or injury. Duration and intensity of cognitive rehabilitation programs vary.


CPT codes:

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.

97533 Sensory integration therapy is addressed in a separate policy. (See Related Policies)

Place of Service

Cognitive rehabilitation can occur in either the inpatient or outpatient setting.


Note: See Benefit Application when reviewing cognitive rehabilitation for children.

Cognitive rehabilitation (CR) 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, a 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. Sensory integration therapy is addressed in a separate medical policy. (See Related Policies)


Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply.

Benefit Application

Note: When reviewing cognitive rehabilitation services, some contracts contain language about benefits limitations.

For example, some contracts limit benefits for rehabilitative, education, or training services or supplies for dyslexia, for attention deficit disorders, and for disorders or delays in the development of a child's language, cognitive, motor or social skills, including evaluations. The application of these benefit limitations needs to be considered in context of the nature of the particular illness.

These contract limitations may not apply to the treatment of neurodevelopmental disabilities in children under a defined age, as specified by the benefit contract. Check the contract for a neurodevelopmental benefit to determine if cognitive rehabilitation may be considered a component of neurodevelopmental treatment.


This policy was initially developed 1997. The policy has been reviewed on a regular basis using MEDLINE literature searches. The most recent literature search was conducted for the period April 2012 March 2013. Following is a summary of the key literature

This policy was originally based on a 1997 TEC Assessment. (1) The Assessment addressed a broad range of patient indications resulting from neurological 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. For the purposes of this Assessment, cognitive test performance is not considered a health outcome. Results of instruments assessing daily functioning or quality of life are considered health outcomes.

For the Assessment’s main evidence review, randomized, controlled trials 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 upon 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 beyond completion of the intervention program.

Eleven randomized, controlled trials (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 eleven 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 cognitive test outcomes is plagued by numerous methodological 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 one study was there consistency across several cognitive test scores showing better performance with cognitive rehabilitation.

In summary, the RCTs 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 neuropsychological 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 neuropsychological 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 neuropsychological 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 RCTs on cognitive training that met study selection criteria, none of which reported any statistically significant between-group differences on any outcomes. An RCT was published in 2003 by Spector et al. (7) A total of 115 subjects were randomized to receive a cognitive simulation 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 of 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 data were discussed in a 2006 meta-analyses on cognitive training in Alzheimer’s disease (8). One study reported on patients that have 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 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 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


Recent reports on cognitive rehabilitation and encephalopathy were limited to two small, uncontrolled series. While both series reported favorable results with rehabilitation, the data are inadequate to change the conclusions of the 1997 Assessment. (14,15)


The effectiveness of cognitive rehabilitation for stroke was assessed in three Cochrane reviews that separately evaluated memory deficits, attention deficits, and spatial neglect. (16,17)

  • 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 two controlled trials involving 56 patients. The review concluded that there is some indication that training improves alertness and sustained attention but no evidence 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 15 studies involving 400 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 (18).

An article by Caltagirone describes telecommunications technology for stroke patients undergoing cognitive rehabilitation. He states that the impact of cognitive impairment on daily functioning may be even greater than that of physical limitations in affected patients, contributing to the high cost of brain disorders. His article explores the future of new technologies, including telerehabilitation, and states that they may provide an effective response to this challenge of high costs, allowing increased access to rehabilitation services as well as reduced care costs for individuals needing cognitive rehabilitation. (19)

Although the evidence to support cognitive rehabilitation for stroke patients is not robust, there is some evidence suggesting that it may improve functional outcomes in some patients

Practice Guidelines and Position Statements

The National Academy of Neuropsychology has an official statement on cognitive rehabilitation and acquired brain injuries, issued in 2002 with no recent update:

“The National Academy of Neuropsycholology supports such empirically and rationally based cognitive rehabilitation techniques that have been designed to improve the quality of life and functional outcomes for individuals with acquired brain injuries. There remains a need for more evidenced-based work to further define and tailor cost-effective cognitive rehabilitation interventions (Ricker, 1998), and also for an expansion of the graduate academic curriculum by offering training courses in neuropsychological rehabilitation to adequately prepare clinical neuropsychologists to assess for rehabilitation and to treat individuals with brain injuries (Uzzell, 2000). Most importantly, the last several decades have created a clinical and empirical foundation to provide patients with effective cognitive rehabilitation interventions to promote neurobehavioral recovery and to improve opportunities for returning to productive lives.”

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 I 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 outcomes measures.

The VA/Department of Veterans Affairs (DoD) published guidelines on the treatment of concussion/mild traumatic brain injury (TBI) 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].


  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.Salazar AM, Warden DL, Schwab K et al. Cognitive rehabilitation for traumatic brain injury: a randomized trial. JAMA 2000; 283:3075-81.
  3. 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; 85:943-50.
  4. Cicerone KD, Mott T, Azulau J et al. A randomized controlled trial of holistic neuropsychologic rehabilitation after traumatic brain injury. Arch Phys Med Rehabil 2008; 89(12):2239-49.
  5. 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.
  6. Spector A, Thorgrimsen L, Woods B et al. Efficacy of an evidence-based cognitive stimulation therapy programme for people with dementia: randomized controlled trial. Br J Psychiatry 2003; 183(3):248-54.
  7. Sitzer DI, Twamley EJ, Jeste DW. Cognitive training in Alzheimer’s disease: A meta-analysis of the literature. Acta Psychiatr Scand 2006; 114:75-90.
  8. 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.
  9. Lowenstein 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.
  10. 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.
  11. 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.
  12. 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].
  13. Lindgren M, Hagstadius, S, Abjoernsson G et al. Neuropsychological rehabilitation of patients with organic solvent-induced chronic toxic encephalopathy; a pilot study. Neuropsychological Rehabilitation 1997; American Psychologic Association; Psychology Press, United Kingdom.
  14. Schmidt JG, Drew-Cates J, Dombovy ML. Anoxic encephalopathy; outcome after inpatient rehabilitation. J Neurologic Rehabilitation 1997; American Psychologic Association; Demos Publications, Inc., United States.
  15. Nair RD, Lincoln NB. Cognitive rehabilitation for memory deficits following stroke. Cochrane Database Syst Rev 2007; (3):CD00293.
  16. Lincoln NB, Majid MJ, Weyman N. Cognitive rehabilitation for attention deficits following stroke. (Cochrane Review). In: The Cochrane Library, Issue 1, 2002.
  17. Bowen A, Lincoln NB, Dewey M. Cognitive rehabilitation for spatial neglect following stroke. Cochrane Database Syst Review2007; (2):CD003586.
  18. Diamond PT. Rehabilitative management of post-stroke visuospatial inattention. Disabil Rehabil 2001; 23(10):407-12.
  19. Caltagirone C, Zannino GD. Telecommunications technology in cognitive rehabilitation. Funct Neurol. 2008;23(4):195-9.
  20. National Academy of Neuropsychology. Cognitive Rehabilitation. Official Statement of the National Academy of Neuropsychology. May 2002. Last accessed August, 2013.
  21. Institute of Medicine, National Academies Press. Cognitive rehabilitation therapy for traumatic brain injury. 2011, October. Available online at: Last accessed August, 2013.
  22. 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.
  23. BlueCross BlueShield Association Medical Policy Reference Manual, Cognitive Rehabilitation. Medical Policy Reference Manual, Policy No. 8.03.10, 2013.







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



Community/work reintegration training (e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact by provider, each 15 minutes

ICD-9 Procedure


Rehabilitation, not elsewhere classified

ICD-9 Diagnosis


Other cerebral degenerations



Encephalopathy, unspecified



Cerebral thrombosis with cerebral infarction



Cerebral embolism with cerebral infarction



Unspecified cerebral artery occlusion with cerebral infarction



Cognitive deficits



Symbolic dysfunction, unspecified



Alexia and dyslexia



Attention or concentration deficit



Cognitive communication deficit



Frontal lobe and executive function deficit



Other signs and symptoms involving cognition






Cerebral laceration and contusion



Subarachnoid, subdural and extradural hemorrhage, following injury



Other and unspecified intracranial hemorrhage following injury



Intracranial injury of other and unspecified nature



Personal history of traumatic brain injury



(effective 10/01/14)

S06.0 - S06.9x9-

Traumatic brain injury, code range

(effective 10/01/14)


Physical Rehabilitation Speech



Physical Rehabilitation Motor Treatment



Physical Rehabilitation – Activities of Daily Living Treatment

Type of Service



Place of Service










Add to Therapy Section - New Policy


Replace Policy - New CPT codes; expanded description.


Replace Policy - Policy updated; no change in policy statement. Rationale expanded, new references added.


Replace Policy - CPT code updates only.


Replace Policy - Policy updated; no change in policy statement; references added.


Replace Policy - Policy updated with literature search; references added; no change in policy statement.


Replace Policy - Policy updated with literature review; references added. No change in policy statement.


Replace Policy - Policy updated with literature search; no change to the policy statement. References added.


Benefit Application Update - No other changes.


Replace Policy - Policy updated with literature search. Policy statement changed: Traumatic brain injury and stroke, previously considered investigational, may now be considered medically necessary. References added.


Replace Policy - Policy updated with literature review; no change in policy statement.


Replace policy. Policy updated with literature review; Rationale section extensively revised. References added, removed, and renumbered. No change in policy statement.


Replace policy. Policy reviewed. Literature review through March 2013 did not prompt any additions to the reference list. Diagnosis codes added. Policy statement unchanged. Add ICD-10 codes.


Replace policy. Policy guideline about cognitive rehabilitation limitation of up to 24 months from the onset of the injury or illness is removed. Policy statement unchanged.

Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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