Statement - ASHA Advocates for Health Plan Coverage of Cognitive Rehabilitation

Janet McCarty, MEd, CCC-SLP
Private Health Plan Advisor, ASHA Health Care and Economics and Advocacy Unit

The American Speech-Language-Hearing Association (ASHA) advocates for coverage of speech-language pathology services, including cognitive rehabilitation, for patients with communication disorders resulting from head injury. A number of health plans deny cognitive rehabilitation claiming the treatment is "investigational" and lacks evidence. However, ASHA has collected a significant amount of research evidence that clearly supports cognitive rehabilitation provided by speech-language pathologists. In addition, independent review organizations are overturning denials for this treatment, noting in one case, "that the therapy at issue is likely to be more beneficial" than other treatments, and in another case, that "treatment as recommended and provided by the therapist is recognized as being appropriate, invaluable in the treatment of mild traumatic brain injury and should be reasonably covered treatment."

The Blue Cross Blue Shield Association's Technology Evaluation Center (TEC) issued a report in 1997, updated in 2002, which said that there was inadequate evidence to make conclusions about the effectiveness of cognitive rehabilitation. The report called the treatment "investigational." ASHA disagrees, noting significant research to support this treatment area. A 2000 literature review in the Archives of Physical Medicine and Rehabilitation reports "clear evidence supporting the effectiveness of cognitive rehab for subjects with acquired TBI or stroke." In this review, 29 Class I research studies (the most rigorous form of research design) supported cognitive remediation for impairments of attention, functional communication, memory, problem solving, and visual scanning. An update of this review in 2005 found 16 of 17 Class I studies, (the category with the most rigorous research design) providing evidence for the effectiveness of cognitive rehabilitation.

ASHA's treatment efficacy report on cognitive-communicative disorders resulting from TBI shows that patients receiving early intervention services were discharged at higher levels of cognitive functioning. Gains were shown by 84% of the patients treated for memory, 85% for attention, and 87% for pragmatics. Additionally, these patients had a higher percentage of discharge to home versus long-term care facilities.

Cognitive rehabilitation has been endorsed by a National Institutes of Health Consensus Panel, which notes that studies exist that support this treatment even though research in this area is "exceedingly difficult to conduct," (NIH Consensus Statement, 1998; 16:1-41).

Given the body of research evidence supporting cognitive rehabilitation, ASHA urges health plans to recognize the scientific support for this treatment and to cover this vital procedure for individuals experiencing the profound impact of neurological insult.