Blue Cross and Blue Shield health insurance plans are denying cognitive rehabilitation services provided by speech-language pathologists, claiming that treatment is "investigational." BlueCross BlueShield of Kansas City (MO) and Regence BlueCross BlueShield of Oregon have denied speech-language pathology services for cognitive rehabilitation, with the Missouri insurer noting that this covers all applications, including traumatic brain injury (TBI), stroke, post-encephalic patients, and the aging population, including Alzheimer's patients.
This policy stems from a BlueCross BlueShield Association (BCBSA) Technology Evaluation Center (TEC) report dated December 2002 that states, "Available data are considered insufficient to make conclusions on whether cognitive rehabilitation results in beneficial health outcomes." BCBSA is an association for 41 independently owned and operated BlueCross and BlueShield Plans that each sets its own medical policy and coverage decisions, but member plans will often use BCBSA reports to support medical coverage policy. TEC assessment reports are systematic literature reviews on a procedure's effectiveness that are intended to produce objective, reproducible analyses.
Challenging the Blues
In a September 2004 letter to BCBSA, ASHA strongly disagreed with the Blues Association conclusion and provided support for this vital treatment for individuals experiencing cognitive disorders as the result of neurological insult. In an article entitled "Evidence-Based Cognitive Rehabilitation: Recommendations for Clinical Practice," published in the Archives of Physical Medicine and Rehabilitation (Dec. 2000), the authors report "clear evidence supporting the effectiveness of cognitive rehabilitation for subjects with acquired TBI or stroke," including impairments of attention, functional communication, memory, problem solving, and visual scanning. ASHA also offered data gathered from its National Outcomes Measurement System (NOMS) that showed improvements in attention, memory, and pragmatics for patients with cognitive-communication deficits, as well as a treatment efficacy fact sheet that showed patients who receive early intervention services were discharged at higher levels of cognitive functioning.
Calls to the American Occupational Therapy Association and the American Psychological Association indicated that members of these associations are not experiencing claim denials, but representatives noted that this is not a large practice area for either professional.
In response to the BCBSA claim that cognitive rehabilitation is investigational, ASHA is conducting its own systematic review of the literature on this topic. Questions will focus on functional outcomes associated with cognitive rehabilitation, its effect on memory, attention, and problem solving, outcomes by etiology and delivery setting, and length of treatment variables.
In addition, ASHA will assist members and patients who have been denied coverage for cognitive rehabilitation because it is "investigational," taking it to the external claim review level, if necessary. According to staff at the National Association of Insurance Commissioners, if a patient prevails at the external review level, health plans must pay for the treatment, but more importantly, a precedent is established. Currently, 42 states have an external review process (go to the Georgetown University Health Policy Institute Web site for each state's procedure and contact points).
As a further note, code selection does not seem to make a difference in denial rates. Whether you use 97532 (development of cognitive skills to improve attention, memory, problem solving) or 92507 (treatment of speech, language, communication disorder), claims decisions are based on progress notes that are reviewed for details about the nature of treatment goals.