Coverage Policy Manual
Policy #: 1997036
Category: Rehabilitation
Initiated: July 1993
Last Review: September 2023
  Cognitive Rehabilitation
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 various intervention strategies or techniques that attempt to help patients reduce, manage, or cope with cognitive deficits caused by brain injury. The desired outcomes are improved quality of life and function in home and community life. The term rehabilitation broadly encompasses reentry into familial, social, educational, and working environments, the reduction of dependence on assistive devices or services, and general enrichment of quality of life. Patients recuperating from traumatic brain injury have traditionally been treated with some combination of physical therapy, occupational therapy, and psychological services as indicated. Cognitive rehabilitation is considered a separate service from other rehabilitative therapies, with its own specific procedures.
 
Sensory integrative therapy may be considered a component of cognitive rehabilitation. However, sensory integration therapy is considered separately in policy No. 2003043.
Policy/
Coverage:
Effective March 2022
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
Cognitive Rehabilitation (as a distinct and definable component of the rehabilitation process) meets primary coverage criteria that there be scientific evidence of effectiveness in the rehabilitation of patients with severe traumatic brain injury subject to all member contract limitations including the maximum of 60 days per Covered Person per lifetime, provided the following criteria are met:
 
    • Severe traumatic brain injury defined as a sudden trauma causing damage to the brain as a result of the head suddenly and violently hitting an object or an object piercing the skull and entering brain tissue with an extended period of unconsciousness or amnesia after the injury or a Glasgow Coma Scale below 9 within the first 48 hours of injury.
    • Services must be provided by a qualified licensed professional and must be prescribed by the physician.
    • Patients must be able to actively participate in the program.
 
Note: Ongoing services are considered necessary only when there is demonstrated continued objective improvement in function.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Cognitive Rehabilitation (as a distinct and definable component of the rehabilitation process) does not meet primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for all other applications, including, but not limited to, stroke, post-encephalitic or post-encephalopathy patients, autism spectrum disorder, seizure disorders, multiple sclerosis, the aging population, including patients with Alzheimer disease, patients with cognitive deficits due to brain tumor or previous treatment for cancer and patients with post-acute cognitive sequelae of SARS-CoV-2 infection.
 
For contracts without primary coverage criteria, Cognitive Rehabilitation (as a distinct and definable component of the rehabilitation process) is considered investigational for all other applications, including, but not limited to, stroke, post-encephalitic or post-encephalopathy patients, autism spectrum disorder, seizure disorders, multiple sclerosis, the aging population, including patients with Alzheimer disease, patients with cognitive deficits due to brain tumor or previous treatment for cancer and patients with post-acute cognitive sequelae of SARS-CoV-2 infection. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Effective October 2010 through February 2022
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
Cognitive Rehabilitation (as a distinct and definable component of the rehabilitation process) meets primary coverage criteria that there be scientific evidence of effectiveness in the rehabilitation of patients with severe traumatic brain injury subject to all member contract limitations including the maximum of 60 days per Covered Person per lifetime, provided the following criteria are met:
 
    • Severe traumatic brain injury defined as a sudden trauma causing damage to the brain as a result of the head suddenly and violently hitting an object or an object piercing the skull and entering brain tissue with an extended period of unconsciousness or amnesia after the injury or a Glasgow Coma Scale below 9 within the first 48 hours of injury.
    • Services must be provided by a qualified licensed professional and must be prescribed by the physician.
    • Patients must be able to actively participate in the program.
 
Note: Ongoing services are considered necessary only when there is demonstrated continued objective improvement in function.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Cognitive Rehabilitation (as a distinct and definable component of the rehabilitation process) does not meet primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for all other applications, including, but not limited to, stroke, post-encephalitic or post-encephalopathy patients, and the aging population, including Alzheimer’s patients.
 
For contracts without primary coverage criteria, Cognitive Rehabilitation (as a distinct and definable component of the rehabilitation process) is considered investigational for all other applications, including, but not limited to, stroke, post-encephalitic or post-encephalopathy patients, and the aging population, including Alzheimer’s patients.  Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Effective, July 1993 – September 2010
For Member Benefit Contracts or Plans with Primary Coverage Criteria, Cognitive Remediation is not covered because they fail to meet the Primary Coverage Criteria (“The Criteria”) of the applicable benefit certificate or health plan. (The Criteria require, among other things, that there be scientific evidence of effectiveness, as defined in The Criteria.  The Criteria exclude coverage of treatments, such as Cognitive Remediation for which there is lack of scientific evidence).
 
For Member Benefit Contracts or Plans with explicit exclusion language for experimental or investigational services, Cognitive Remediation is not covered because it is considered experimental or investigational treatment, as defined in the applicable benefit contract or health plan, which excludes coverage of experimental or investigational treatment or services.
Rationale:
The available evidence on cognitive rehabilitation for Alzheimer’s disease and related dementias is inadequate to permit conclusions. A double-blind randomized placebo-controlled crossover trial of 37 patients with Alzheimer’s disease suggested that although the intervention produced small gains in learning personal information and attention, improvement did not generalize to overall neuropsychologic functioning, memory, or patient quality of life as detected by caregivers. A second study involved a non-randomized pilot comparison of two different cognitive stimulation interventions in 22 patients with Alzheimer’s disease. Significant improvement in functional living skills was reported for both groups, but training effects regressed to pre-treatment levels after three months.  Some studies of cognitive stimulation in dementia have reported positive findings, but interpretation of these results is impeded by methodological problems or the studies have reported intermediate rather than health outcomes.
 
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.
 
The effectiveness of cognitive rehabilitation for stroke was assessed in three 2002 Cochrane reviews that separately evaluated memory deficits, attention deficits, and spatial neglect.
    • Controlled studies investigating the effectiveness of cognitive rehabilitation in improving memory deficits due to stroke were limited to a single trial of 12 patients. Outcomes showed that memory strategy training had no significant effect on memory impairment or subjective memory complaints, although the study was underpowered to detect differences.
    • 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.
 
No additional evidence was identified that would change the conclusions of the 1997 Assessment for stroke.
 
2010 Update
Traumatic Brain Injury
In 2008, a Blue Cross Blue Shield Association TEC Assessment was completed on cognitive rehabilitation in traumatic brain injury.  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 1 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 (Salazar, 2004).  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 (Cicerone, 2004).  The intervention group showed greater improvements in functioning as assessed by a questionnaire that evaluated community integration, home integration, and productivity assessed on completion of the intervention.
 
A comprehensive program of neuropsychologic rehabilitation was compared to standard rehabilitation in a randomized trial published in 2008 (Cicerone, 2008).  This study was intended to be a more rigorous evaluation of the nonrandomized study (Cicerone, 2004) reviewed in the 2008 TEC Assessment. Sixty-eight patients were randomized to the 2 intervention groups. The principal outcomes measured were the Community Integration Questionaire (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 neuropsychologic 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.
 
Based on the review of the published literature in combination with expert opinion the coverage statement will be changed to include the use of cognitive rehabilitation as a distinct and definable component of the rehabilitation process as part of the treatment of those with traumatic brain injury.  There were no studies found that would prompt a change in the coverage statement in regards to any other indications.
 
2012 Update
This policy is being updated with a literature review through August 2012. There was no new information identified that would prompt a change in the coverage statement.
 
Kurz et al. published an RCT in 2011 for patients with Alzheimer’s disease and early dementia (Kurz, 2011). 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.
 
The Institute of Medicine published a report in October 2011 titled “Cognitive Rehabilitation Therapy for Traumatic Brain Injury” 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 in 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 outcome measures.
 
2013 Update
A search of the MEDLINE database through August 2013 did not reveal any new information that would prompt a change in the coverage statement.   
 
2014 Update
A literature search conducted through August 2014 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
In 2013, the Cognitive Rehabilitation Task Force of the American Congress of Rehabilitation Medicine (ACRM) published a systematic review of cognitive rehabilitation in medical conditions affecting cognitive function (Langenbahn, 2013). Of 11 clinical conditions reviewed, there was evidence to support a practice guideline only for children and adolescents with brain tumors who undergo surgical resection and/or radiation therapy.
 
Traumatic Brain Injury
A 2013 Cochrane review assessed cognitive rehabilitation for executive dysfunction (planning, initiation, organization, inhibition, problem solving, self-monitoring, error correction) in adults with nonprogressive acquired brain damage (Chung, 2013). Sixteen RCTs (total N=660; 395 traumatic brain injury, 234 stroke, 31 other acquired brain injury) were included in pooled analyses. No statistically significant effects on measures of global executive function or individual component functions were found.
 
Dementia, including Alzheimer Disease
The use of cognitive training (task-focused) or rehabilitation (strategy-focused) in Alzheimer disease and vascular dementia was evaluated in a 2013 Cochrane review (Bahar-Fuchs, 2013). Evidence from 11 RCTs did not demonstrate improved cognitive function, mood, or activities of daily living in patients with mild to moderate Alzheimer disease or vascular dementia with cognitive training.
 
Epilepsy/Seizure Disorders
The 2013 systematic review by ACRM’s Cognitive Rehabilitation Task Force evaluated cognitive rehabilitation in epilepsy (Langenbahn, 2013). Based on 2 comparative studies (1 randomized; total N=156)), the Task Force recommended cognitive rehabilitation for attention and memory deficits as a “possibly effective” practice option for seizure-related attention and memory deficits. The randomized trial (Engelberts, 2002) prospectively enrolled 50 patients with focal seizures who were receiving carbamazepine monotherapy. Patients were randomized to a retraining method, aimed at retraining impaired cognitive functions (n=19); a compensation method, aimed at teaching compensatory strategies (n=17); or a waiting-list control group (n=8). Both interventions focused on divided attention (ability to multi-task). At 6-month follow-up, performance on cognitive tests improved more in both intervention groups compared with control. No difference in inhibitory capacity was observed. Self-reported cognitive complaints, absentmindedness, and quality of life improved more with cognitive rehabilitation. Overall, rehabilitation methods were similarly effective.
 
The nonrandomized study () assessed short-term effects of cognitive rehabilitation on memory deficits in 2 retrospective, matched cohorts of temporal lobe epilepsy surgical patients. Mean age (SD) was 36 (10) years; mean age (SD) at onset of epilepsy was 4 (1) years; and mean IQ was 105. Patients who received cognitive rehabilitation (n=55) participated in a 1-month program comprising educational sessions about brain function and cognitive exercises. A cohort of 57 patients received no cognitive rehabilitation. Statistically significant improvements in verbal learning and recognition were observed in right-resected patients who received cognitive rehabilitation. Cognitive rehabilitation had nonsignificant effects in left-resected patients. Limitations of the study include its retrospective design and baseline imbalances in memory and attention deficits (more severe deficits in the control cohort).
 
Koorenhof et al (2012) studied left temporal lobe epilepsy surgical patients (Koorenhof, 2012). Twenty (87%) of 23 recruited surgical candidates completed a total of 4 hours of pre- and/or postoperative memory training and up to 40 sessions of Lumosity©, a web-based cognitive training program. Three to 6 months after surgery, statistically significant improvements on verbal learning and recall tests were observed. After training, patients reported subjective improvements in memory failures (repeated-measures MANOVA, p<0.3) and memory nuisance (p<0.005). Preoperative memory training was not associated with better outcomes than postoperative training. Improvements in verbal learning were associated with improved mood (r= -0.58, p<0.008).
 
Chiappedi et al (2011) reported a retrospective cohort study of 156 children (mean age [SD], 7.6 [6.4] years) with developmental disorders (eg, cerebral palsy, congenital anomalies) and epilepsy who received comprehensive rehabilitation in Italy (Chiappedi, 2011). Programs comprised physical therapy, psychomotor rehabilitation including cognitive training, and/or speech and language rehabilitation. Most patients (62%) had severe disability, most (62%) had severe or profound cognitive deficits, and 22% had daily seizures. Because patients were heterogeneous, validated assessment tools were not identified; instead, response to rehabilitation was defined by the treating physician as present or absent. More children who received speech and language rehabilitation responded compared with those who did not (p<0.001). The proportion of responders was similar between groups that did or did not receive psychomotor rehabilitation (p=0.10). In multivariate analysis, negative predictors of treatment response were severity of impairment (odds ratio [OR], 0.02; 95% confidence interval [CI], 0.01 to 0.14) and daily seizures (OR=0.22; 95% CI, 0.08 to 0.58).
 
Autism Spectrum Disorders
In 2013, Reichow et al reported a systematic review of psychosocial interventions administered by nonspecialists for children and adolescents with intellectual disability (IQ<70) or lower-functioning autism-spectrum disorders (Reichow, 2013). Five comparative trials in patients with autism-spectrum disorders (total N=255) who received cognitive rehabilitation, training, and support were included. Improvements in school performance and developmental outcomes were inconsistent across trials.
Wang et al (2013) conducted a pilot study of a novel virtual reality-cognitive rehabilitation intervention in 4 children (mean age, 7.4 years) with autism (Wang, 2013). Children with autism, who are difficult to engage, may respond better to virtual reality approaches than to traditional cognitive rehabilitation. Mean nonverbal IQ ranged from 93 to 139. Each child viewed training programs on laptop computers equipped with tracking webcams; the child’s image and movements were projected into virtual environments where he/she was required to manipulate virtual objects. Outcomes were measures of contextual processing, defined as “the ability to determine an object’s meaning or relevance in a particular context,” and of abstraction and cognitive flexibility, executive functions considered components of contextual processing. After 4 to 6 weeks, all children demonstrated statistically significant improvements in contextual processing and cognitive flexibility. Abstraction scores at baseline were at or close to maximum.
 
Eack et al conducted a feasibility study of a comprehensive cognitive rehabilitation intervention, called Cognitive Enhancement Therapy, in 14 “high-functioning” adults (mean age [SD], 25 [6] years) with autism-spectrum disorders (Eack, 2013). Cognitive Enhancement Therapy, originally developed for schizophrenic patients, provides social interaction and cognitive training focused on attention, memory, and problem solving. Mean full scale IQ of the patient sample was 118 (range, 92-157). Eleven (79%) of 14 patients completed 18 months of treatment. Statistically significant changes from baseline were observed in mean composite measures of neurocognition, cognitive style, social cognition, and social adjustment. All components of neurocognition (eg, processing speed, working memory) improved statistically except attention/vigilance.
 
Clinical Input Received Through Physician Specialty Societies and Academic Medical Centers
In response to requests, input was received from 2 physician specialty societies and 5 academic medical centers while this policy was under review in 2009 and 2010. While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted. The strongest support was for use of cognitive rehabilitation as part of the treatment of those with traumatic brain injuries. The level of support varied for other diagnoses such as use in poststroke patients.
 
Ongoing Clinical Trials
Online site, ClinicalTrials.gov currently lists more than 200 studies of cognitive rehabilitation for the following clinical conditions: acquired brain injury; breast, ovarian, and pediatric cancer survivorship; cancer chemotherapy-induced cognitive impairment; postmalaria cognitive impairment in children; cocaine abuse; multiple sclerosis; Parkinson disease; posttraumatic stress disorder in veterans; schizophrenia; sickle cell disease; and stroke.
 
Summary
For patients with traumatic brain injury, there are numerous RCTs evaluating the efficacy of cognitive rehabilitation. However, these trials have methodologic limitations and report mixed results, indicating that there is not a uniform or consistent evidence base supporting the efficacy of this technique. Based on review of published trials, together with clinical input and consideration of limited alternative treatments, use of cognitive rehabilitation as a distinct and definable component of the rehabilitation process may be considered medically necessary as part of the treatment of those with traumatic brain injury.
 
For other indications, evidence on cognitive rehabilitation is insufficient to permit conclusions, and clinical input did not uniformly favor cognitive rehab. Therefore, use of cognitive impairment in disease states other than traumatic brain injury is considered investigational
 
Practice Guidelines and Position Statements
American Congress of Rehabilitation Medicine, Brain Injury Interdisciplinary Special Interest Group, Cognitive Rehabilitation Task Force
 
Based on a 2013 systematic review, the Task Force recommended process-based cognitive rehabilitation strategies (eg, attention process training, strategy acquisition and internalization, self-monitoring, and corrective feedback) to treat attention and memory deficits in children and adolescents with brain cancers who undergo surgical resection and/or radiation therapy (Langenbahn, 2013).
 
National Institute for Health and Care Excellence
NICE guidance (2013) on stroke rehabilitation recommends cognitive rehabilitation for visual neglect and memory and attention deficits that impact function (NICE, 2013). Interventions should focus on relevant functional tasks, eg, errorless learning and elaborative techniques (mnemonics, encoding strategies) for memory impairments
 
2015 Update
A literature search conducted through May 2015 did not reveal any new information that would prompt a change in the coverage statement.  The key identified literature is summarized below.
 
For patients with traumatic brain injury, there are numerous randomized controlled trials (RCTs) that evaluate the efficacy of cognitive rehabilitation. However, these trials have methodologic limitations and report mixed results, indicating there is not a uniform or consistent evidence base supporting the efficacy of this technique. However, alternative treatments for cognitive deficits due to traumatic brain injury are limited, and there is potential for significant reduction in adverse outcomes. Evidence is therefore considered sufficient to determine that cognitive rehabilitation as a distinct and definable component of the rehabilitation process improves the net health outcome in patients with cognitive deficits due to traumatic brain injury.
 
For the aging population, including patients with Alzheimer disease, and for patients with cognitive deficits due to stroke, post-encephalopathy, autism spectrum disorder, seizure disorder, multiple sclerosis, brain tumor, or previous treatment for cancer, evidence on cognitive rehabilitation is insufficient to permit conclusions, and clinical input did not uniformly favor cognitive rehabilitation. Although the body of evidence includes RCTs, methodologic limitations limit conclusions that may be drawn. Larger studies with longer follow-up are needed to demonstrate durable benefits of cognitive rehabilitation therapy in these patients.
 
Clinical Input Received From Physician Specialty Societies and Academic Medical Centers
 
2015 Input
In response to requests, input was received from 3 physician specialty societies and 5 academic medical centers while this policy was under review in 2015. Input was mixed on cognitive rehabilitation for patients with stroke, MS, brain tumors, or cognitive impairments after previous treatments for cancer.
 
2016 Update
A literature search conducted through August 2016 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
Chiaravalloti and colleagues conducted an RCT of the Story Memory Technique to improve learning and memory in subjects with TBI (Chiaravalloti, 2015).  Sixty-nine subjects were randomized to treatment or control. Assessments were performed at the end of treatment (5 weeks) and at 6 months posttreatment. Outcomes were statistically significant in favor of the treatment group for several measures assessing memory at 5 weeks. Results at 6 months were less definitive.
 
Huntley and colleagues performed a meta-analysis of cognitive interventions in dementia (Huntley, 2015).  Thirty-three studies were included. Interventions were divided into categories such as cognitive training, cognitive stimulation, and cognitive rehabilitation. Studies classified as cognitive stimulation had a significant effect as measured on the Mini-Mental State Examination (MMSE) and the Alzheimer ’s disease Assessment Scale‒Cognition (ADAS-Cog). The authors concluded that benefit measured on the ADAS-Cog was generally not clinically significant.
 
Hanssen and colleagues carried out a RCT of cognitive rehabilitation in patients with MS (Hanssen, 2016).  One hundred twenty patients were randomized to 4 weeks of multidisciplinary cognitive rehabilitation or 4 weeks of standard rehabilitation. Outcomes for executive function did not differ significantly between groups at 4 or 7 months after the start of the intervention. Only a health-related QOL measure relating to psychologic health showed a difference between intervention and control favoring intervention.
 
Farina and colleagues (2015) in Italy conducted a systematic review of the literature on cognitive rehabilitation in epilepsy (Ercoli, 2015).  Literature was searched through December 2013, and 18 articles of different types (reviews, methodologic papers, case reports, experimental studies) were identified. Studies were heterogeneous in patient characteristics (type of epilepsy, type of previous treatment [surgery, antiepileptic drugs]), intervention modalities (eg, holistic, focused) and duration, and outcome measures. Reviewers considered the overall quality of evidence to be moderate to low, and results inconsistent (eg, not all studies showed benefit; some showed greater benefit in left-sided seizures and others showed greater benefit in right-sided seizures).
 
2017 Update
A literature search conducted through August 2017 did not reveal any new information that would prompt a change in the coverage statement.  The key identified literature is summarized below.
 
Randomized Controlled Trials
Ameiva and colleagues reported results of the ETNA3 multicenter RCT comparing 4 therapies strategies: standardized programs of cognitive training (group sessions), reminiscence therapy (group sessions), individualized cognitive rehabilitation program (individual sessions), and usual care (ameiva, 2016). Six hundred fifty-three patients with mild-to-moderate AD were randomized in a 1:1:1:1 ratio at 40 French clinical sites. This summary will focus on the cognitive rehabilitation program and usual care arms. The primary outcome was the rate of survival without moderately severe to severe dementia at 2 years. Secondary outcomes were cognitive impairment, functional disability, behavioral disturbance, apathy, QOL, depression, caregiver burden, and resource utilization. Participants and clinical staff were not blinded to treatment assignment but outcome assessments were done by blinded physicians and psychologists. The cognitive rehabilitation therapy consisted of a made-to-measure program and conducted in individual sessions and adapted to the patients’ cognitive abilities with goals selected to be personally relevant to the patient. Intention-to-treat analyses were performed using “missing equal failure” to replace missing values. Approximately 90% of participants had the 3-month follow-up visit and 72% had the 24 month visit. There was no difference between the cognitive rehabilitation group and the usual care group with respect to the primary outcome. However, the patients who received the cognitive rehabilitation therapy had less functional decline at 24 months compared to the usual care group as measured by 1 of the 2 scales assessing functional abilities: AGGIR scale (p=0.02). The rate of institutionalization was lower in the cognitive rehabilitation therapy group than in the usual care group (27% vs 19%). These results are promising but given the lack of consistency in benefit on the 2 functional scales, replication is needed to confirm positive findings.
 
Regan and colleagues reported an RCT of a home-based, 4-session, goal-oriented cognitive rehabilitation program versus usual care in 55 patients with mild cognitive impairment (MCI) and early AD (Regan, 2017). Patients were community-dwelling with a diagnosis of MCI or AD within 6 months of enrollment and a MMSE score greater than 20. The intervention group received 4 weekly 1-hour therapy sessions delivered by experienced therapists with a focus on addressing personally meaningful goals. All participants identified at least 1 goal for improvement. The usual care group had no contact with the research team between their initial and final assessments. The primary outcome measures were goal performance and satisfaction scores on the Canadian Occupational Performance Measure (COPM). Twelve participants in the intervention group and 3 participants in the control group discontinued study participation and were excluded from the final, per-protocol analysis. For the first identified goal, the intervention group had significantly higher improvement in performance and satisfaction on the COPM compared to the control group. There were no differences in secondary measures of QOL or anxiety and depression. The per-protocol results are biased due to high rate of missing data.
 
 
In a 2016 update, das Nair and colleagues included 15 studies with 989 patients. There were no differences in subjective reports of memory functioning or mood (das Nair, 2016-Mar). There was some evidence of a significant effect of intervention on objective assessments of memory in both the immediate and long-term follow-up and QOL in intermediate follow-up. However this effect on objective memory outcomes and quality of life changed from statistically significant to not significant when studies at high risk of bias were excluded.
 
Zeng and colleagues published a systematic review and meta-analysis of neuropsychological intervention for cognitive function in cancer survivors (Zeng, 2016). Three case control studies and 7 RCTs with 433 patients (range, 22-98 patients) published between January 2010 and September 2015 were included. Most trials assessed the immediate effects of the intervention at post-intervention or with short-term follow- up of 6 months or less. More than half of the trials were conducted in breast cancer survivors. Three trials assessed the effects of cognitive rehabilitation programs and the weighted mean difference for the intervention effect at post-intervention follow-up was -0.19 (95% CI, -2.98 to 2.61).
 
ONGOING AND UNPUBLISHED CLINICAL TRIALS
Some currently ongoing clinical trials that might influence this review are listed below:
 
(NCT01138020) Cognitive Rehabilitation of Blast-induced Traumatic Brain Injury; planned enrollment 120; projected completion date October 2018
 
2018 Update
Annual policy review completed with a literature search using the MEDLINE database through September 2018. No new literature was identified that would prompt a change in the coverage statement.
 
2019 Update
A literature search was conducted through August 2019.  There was no new information identified that would prompt a change in the coverage statement.  
 
2020 Update
Annual policy review completed with a literature search using the MEDLINE database through August 2020. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
das Nair et al conducted the large (N=328), multicenter, assessor-blinded, A group memory rehabilitation programme for people with traumatic brain injuries (ReMemBrIn) RCT, which involved evaluating a group memory rehabilitation program for people with TBI in 9 sites in England (das Nair, 2019). The group memory rehabilitation intervention involved 10 weekly sessions, each lasting about 1.5 hours, which were delivered by a trained Assistant Psychologist to groups of between 4-6 participants. The intervention focused on retraining memory functions and strategies to improve encoding and retrieval. The control group received usual care, which typically included employment rehabilitation services, self-help groups or receiving specialist charity support. Between 2013 and 2015, 328 individuals were randomized to therapy (N=171) or usual care (N=157). The participants were characterized by a mean age of 45.1 years, a length of initial hospital stay for TBI of 84.2 days, and time since TBI of 100.9 months. On the primary outcome of frequency of memory failures in daily life assessed using the Everyday Memory Questionnaire-patient version at 6 months’ follow-up, the between-group difference was not clinically important (adjusted difference in mean scores –2.1, 95% confidence interval [CI] –6.7 to 2.5; p = 0.37). For secondary outcomes, there was a significant improvement in goal attainment both at 6 and 12 months, but no differences on others such as mood or quality of life. Important methodological limitations included lack of an active control arm, incomplete assessment of intervention fidelity, and exclusion of over 20% of the sample from the primary analysis.
 
Clare et al reported on results from the multicenter, assessor-blinded Individual Goal-oriented Cognitive Rehabilitation to Improve Everyday Functioning for People with Early-stage Dementia (GREAT) RCT that compared individual goal-oriented cognitive rehabilitation to treatment as usual in individuals with early-stage dementia (Clare, 2019). The majority of participants were diagnosed with Alzheimer dementia, their mean age was 78.56 years, and their mean Mini-Mental State Examination (MMSE) score was 23.82 points. The primary outcome was participant-rated 3-month goal attainment. Goals were identified using the semi-structured Bangor Goal-Setting Interview. Attainment was assessed based on a 0-10 scale. Study authors noted that an improvement of 2 points in the goal attainment rating was considered to be clinically significant. Improvement in goal attainment was significantly greater in the therapy group than in the control group both at 3 months and at 9 months. However, there were no significant between-group differences on any of the secondary outcomes at 3 or 9 months, including self-reported self-efficacy (Generalised Self-Efficacy Scale), mood (Hospital Anxiety and Depression Scale), dementia-specific health-related quality of life. memory, (story recall from the Rivermead Behavioural Memory Test), attention (elevator counting and elevator counting with distraction subtests from the Test of Everyday Attention), or executive function (verbal letter fluency from the Delis-Kaplan Executive Function System). No measure of functional ability was assessed.
 
The largest and longest-term RCT conducted in people with multiple sclerosis receiving cognitive rehabilitation was published by Lincoln et al (2020). It is a multicenter, observer-blinded RCT in patients with relapsing-remitting (65%), primary progressive (10%) or secondary progressive MS (25%) (Lincoln, 2019; Lincoln, 2020). Participants were recruited between 2015 and 2017 and randomized to 10 weekly sessions of a group cognitive rehabilitation program (N=245) or usual care (N=204). Outcomes were assessed at 6 and 12 months after randomization. Although there were small improvements in mood and everyday memory problems, there were no significant long-term benefits in cognitive abilities, fatigue, employment, or quality of life. Its main methodological limitation was that there was no sham cognitive rehabilitation group and participants were not masked to treatment assignment.
 
Shahpouri et al conducted a small trial consisting of 56 participants with primarily relapsing remitting multiple sclerosis (Shahpouri, 2019). Ten 2-hour individualized sessions were held every 7-10 days with approaches developed considering the severity of cognitive impairment and with the aim of optimization of the residual functions. This was compared to a group who participated in the same number and duration of sessions, but the content of their sessions did not support cognitive rehabilitation. Memory, attention, quality of life, and depression were all significantly improved within 3 months after study initiation.
 
Chiaravalloti et al conducted a small trial of 20 learning-impaired participants with primarily relapsing remitting multiple sclerosis (Chiaravalloti, 2019). Two 30-45 minute sessions were done each week for 4 weeks. Sessions included guided practice of a set of structured and standardized tasks to train individuals on self-generation, spaced-learning and retrieval practice. This was compared to a group of participants who met individually with a therapist at the same frequency and locations as the treatment group but the non-treatment group engaged in non-training oriented tasks. Although STEM (strategy-based training to enhance memory) improved measures of subjective cognitive function outcomes immediately following the intervention, it did not lead to improved performance on objective neuropsychological functioning.
 
For children with cancer receiving cognitive rehabilitation, the evidence includes 1 small (N=46), single-center RCT by Akel et al (Akel, 2019). The cognitive rehabilitation was delivered in the inpatient treatment clinic of the Department of Pediatric Oncology at University Hospital in Ankara, Turkey. Cognitive skills targeted by the cognitive rehabilitation therapy included place and time orientation, internal and external spatial perception, praxis, attention, visio-motor construction, and thinking operations. Children were characterized by a mean age of 10 years and 55% were male. Cancer diagnoses included non-Hodgkin lymphoma (40%), Hodgkin lymphoma (30%) and bone tumors (30%). Outcomes were evaluated only immediately postintervention. Although compared to the routine therapy groups, numerically larger effect sizes for change in fatigue and functional independence were reported for the cognitive rehabilitation group, it is unknown whether the differences were clinically or statistically significant as the comparative treatment effects were not calculated and clinically significant difference were not prespecified. Significant improvements in cognitive measures were reported pre/post in the intervention group, but no data were reported for the routine therapy group on this outcome. In addition to these inadequate outcome assessment methods, interpretation of these findings is limited by other methodological shortcomings including lack of blinding of participants and lack of long-term follow-up. Therefore, this evidence is not sufficient to draw conclusions on effect on health outcomes.
 
Fernandes et al published a systematic review of cognitive rehabilitation programs in adults with non-CNS cancers. It included 1,124 participants (N range, 11 to 242) from 19 studies published between 2007 and 2018 – the majority of which were RCTs (N=12) (Fernandes, 2019). Waitlist was the most common comparator in the RCTs. As with the previous reviews, most studies in this review assessed the effects of the intervention immediately postintervention or at short-term follow-up (≤6 months) and most trials were conducted in breast cancer survivors. This review did not perform any meta-analyses. Findings across the studies were mixed. Although the review reported that among the RCTs and nonrandomized controlled studies, “87% found short-term improvements on at least one objective cognitive measure,” this finding primarily pertained to measurements taken immediately postintervention. In contrast, in the longest-term (26-month follow-up) and largest trials (N=242) included, there were no significant effects on various objective cognitive measures. Only 63% of studies found improvements in short-term quality of life measures and none found any improvements in functional outcomes. An important limitation of all studies is that participants were not blinded to group assignment.
 
For cancer survivors receiving cognitive rehabilitation, the evidence published subsequent to the above-described systematic reviews includes 1 small (N=25), single-center RCT by Richard et al (Richard, 2019). This RCT randomized 46 participants to Goal Management Training, a Brain Health Program active control that promotes general brain health, and a wait-list control group and reported outcomes immediately following the 8-week treatment period and 4 months following treatment completion. Participants had a mean age of 48 years and 60% were male. Disease characteristics included various tumor types (28% meningioma, 32% low-grade glioma, 24% high-grade glioma) with a mean duration of 23 years since diagnosis. The most common cancer treatment was surgical resection (72%). The most recent type of treatment was whole-brain radiotherapy, which occurred a mean of 3 years prior. The primary outcome measure was change on an investigator-developed executive functioning test composite score. Although compared to the active and wait-list control groups, improvements in executive functioning and real-life functional goal attainment were significantly greater for the Goal Management Training group immediately following treatment, the improvement was only maintained at the 4 month follow-up period for the executive functioning outcome. No quality of life measure was reported. Although the improved executive functioning outcome is encouraging, numerous important study and relevance shortcomings seriously limit the interpretation of these findings. For example, the clinical significance of the executive functioning outcome is unclear as it is not an established measure and its validity is unknown. Additionally, as the executive functioning outcome was not evaluated using an intent-to-treat analysis and excluded a larger proportion of wait-list control group participants than in the Goal Management Training groups (33% vs. 9%), we cannot rule out that the results were biased based on the high and differential exclusions. In addition, interpretation of these findings are limited by other methodological shortcomings including lack of blinding of participants and lack of long-term follow-up. Therefore, this evidence is not sufficient to draw conclusions on effect on health outcomes
 
In 2018, NICE guidance on dementia management suggested: "Consider cognitive rehabilitation or occupational therapy to support functional ability in people living with mild to moderate dementia (NICE, 2018)."
 
2021 Update
Annual policy review completed with a literature search using the MEDLINE database through August 2021. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
110 individuals with MS (22% with relapsing-MS) participated in 13 two hour extended cognitive rehabilitation sessions that was delivered over 6 months (Brissart, 2020). The comparator was 12 two hour non-cognitive exercise sessions delivered over 6 months. Some improvement was observed in the cognitive rehabilitation group in measures of memory function, but there were no differences between groups in executive function or quality of life measures at 6 to 9 month follow-up.
 
2022 Update
Annual policy review completed with a literature search using the MEDLINE database through August 2022. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
The relevant population of interest is individuals with cognitive deficits due to post-acute sequelae of SARS-CoV-2 (PASC) infection. The Centers for Disease Control and Prevention define the post-acute period as symptoms persisting at four or more weeks following infection with SARS-CoV-2 (CDC, 2021). The World Health Organization developed the following consensus case definition of 'post COVID-19 condition': individuals with "a history of probable or confirmed SARS CoV-2 infection, usually 3 months from the onset of COVID-19 with symptoms and that last for at least 2 months and cannot be explained by an alternative diagnosis. Common symptoms include fatigue, shortness of breath, cognitive dysfunction but also others and generally have an impact on everyday functioning. Symptoms may be new onset following initial recovery from an acute COVID-19 episode or persist from the initial illness. Symptoms may also fluctuate or relapse over time" (Soriano, 2021).
 
While subjective reports of cognitive impairment (i.e., 'brain fog') have been reported by individuals not requiring hospitalization, current understanding of objective cognitive sequelae of COVID-19 is predominantly limited to individuals who required hospitalization (Bell, 2021; Fine, 2022; Graham, 2021). Ceban et al conducted a meta-analysis of 43 studies with 12 or more weeks follow-up that reported a 22% overall prevalence of cognitive impairment (95% CI, 17% to 28%; I2=98%; N=13232) (Ceban, 2022). Subjectively ascertained cognitive impairment (e.g., patient self-report) was reported in 18% of patients (95% CI, 12% to 24%; I2=97.9%; 31 studies), which was significantly lower than in studies with objective ascertainment of cognitive status utilizing validated tools (36%; 95% CI, 27% to 46%; I2=94.9%; 12 studies; p=.002). No significant difference in cognitive symptom prevalence was found in subgroup analyses of hospitalized versus non-hospitalized patients (30% versus 20%; p=.096) or patients with <6 months versus ≥6 months of follow-up (22% versus 21%; p=.794).
 
Objective cognitive deficits have been reported for verbal fluency, attention, working memory, processing speed, executive functioning, learning, and memory - with no clear pattern of cognitive impairment across studies. While cognitive impairment following intensive treatment of critical illness is not a new phenomenon, the disease course of cognitive impairment experienced by individuals with post-acute sequelae of SARS-CoV-2 infection is an ongoing research priority (Vrettou, 2022; Oh, 2021).
 
The general outcomes of interest are functional outcomes and quality of life. The natural history of PASC has not been fully categorized, particularly in non-hospitalized individuals. A prospective study measuring cognitive performance among patients who experienced mild disease noted that declines in cognitive scores reported at 6 months spontaneously resolved at 18 month follow-up (Del Brutto, 2021). Persistent cognitive deficits have been reported in 16% of COVID-19 survivors at 1 year who were treated in the intensive care setting (Heesakkers, 2022). Therefore, at least 1 to 2 years of follow-up may be considered necessary to demonstrate efficacy and to fully observe outcomes.
 
The American Academy of Physical Medicine and Rehabilitation Multi-Disciplinary PASC Collaborative issued a consensus guidance statement recommending that patients should be screened for signs of cognitive symptoms using validated tools and instruments, such as the Montreal Cognitive Assessment (MoCA) or MMSE (Fine, 2022).
 
Initial reports of patient rehabilitation after COVID-19 recovery have largely been observational, without clearly identifiable cognitive rehabilitation components within multidisciplinary rehabilitation programs (Imamura, 2021; Albu, 2021). Other reports have primarily focused on respiratory and physical rehabilitation (Liu, 2020; Barbara, 2022).
 
The American Academy of Physical Medicine and Rehabilitation (AAPM&R) Multi-Disciplinary Post-Acute Sequelae of SARS-CoV-2 Infection (PASC) Collaborative issued a consensus guidance statement on the assessment and treatment of cognitive symptoms in patients with PASC (Fine, 2022). PASC cognitive symptom assessment and treatment recommendations are summarized below.
 
Post-Acute Sequelae of SARS-CoV-2 Infection Cognitive Symptom Assessment Recommendations:
 
Recommendation 1 - "Patients should be screened for signs of cognitive symptoms using validated tools and instruments."
Recommendation 2 - "Patients should be evaluated for conditions that may exacerbate cognitive symptoms and warrant further testing and potential subspecialty referral. [...] Particular areas include:
    • Sleep impairment
    • Mood, including anxiety, depression, and posttraumatic stress disorder
    • Fatigue
    • Endocrine abnormalities
    • Autoimmune disorders
Note: Patients often report dissatisfaction with their care because of their persistent symptoms being attributed to psychological factors. It is important to note that mood disorders may be secondary to persistent medical conditions or one of many factors leading to cognitive symptoms."
Recommendation 3 - "Patients should have a thorough neurological examination to identify focal neurological deficits."
Recommendation 3a - "For those patients identified with new or worsening focal neurological deficits (including new or worsening cognitive symptoms) an emergent evaluation is warranted; neuroimaging should be considered."
Recommendation 4 - "The following basic lab workup should be considered to screen for reversible factors contributing to cognitive symptoms. The initial lab workup in new patients or those without lab workup in the 3 months prior to visit including complete blood count, vitamin B12, thiamine, folate, homocysteine, 1,25-dihydroxy vitamin D, magnesium, liver function tests, comprehensive metabolic panel thyroid function tests (thyroid stimulating hormone, free T3, free T4). In high-risk patients, one may consider syphilis rapid plasma regain and human immunodeficiency virus testing [...]"
Recommendation 5 - "Clinicians should conduct a full patient history with review of preexisting conditions and comprehensive medication and supplement review for those that may contribute to cognitive symptoms.
Of note, patients with PASC often present on antihistamine, anticholinergic, and antidepressant/anxiolytic medications that can contribute to cognitive symptoms."
Recommendation 5a - "Clinicians should validate patient history through the collection of collateral history, including preexisting function and conditions, from care team/primary care, patient family or care partner, or close contact as available."
Recommendation 6 - "Clinicians should assess impact of cognitive symptoms using standardized patient-reported assessments, to include activities of daily living, instrumental activities of daily living, school, work and avocational (ie, hobbies), and quality of life."
 
Treatment Recommendations:
 
Recommendation 1 - "For patients who screen positive for cognitive symptoms, refer to a specialist (ie, speech-language pathologist, occupational therapist, neuropsychologist) with expertise in formal cognitive assessment and remediation."
Recommendation 2 - "Treat, in collaboration with appropriate specialists, underlying medical conditions, such as pain, insomnia/sleep disorders (including poor sleep hygiene), and mood disorders that may be contributing to cognitive symptoms."
Recommendation 3 - "Complete, in collaboration with patient primary care provider, medication polypharmacy reduction, weaning or deprescribing medications if medically feasible with emphasis on medications that may impact cognition."
Recommendation 4 - "Reinforce sleep hygiene techniques including nonpharmacologic approaches as first line of sleep remediation."
Recommendation 5 - "Similar to patients experiencing “physical” fatigue, patients should be advised to begin an individualized and structured, titrated return to activity program."
Recommendation 5a - "For patients who achieve a return to their normal, daily activities, regular exercise (at least 2–3 times/week of aerobic exercise) may be effective in improving cognition and also contribute to improved sleep patterns."
Recommendation 5b - "Frequent assessment of the impact of return to normal, daily activities (including school, work, driving, operating heavy machinery, etc.) is recommended to ensure that symptoms do not flare and exercise is tolerated."
 
In 2021, NICE issued a rapid guideline on managing the long-term effects of COVID-19 (NICE, 2021). The guideline recommends using a "multidisciplinary approach to guide rehabilitation, including physical, psychological and psychiatric aspects of management." Cognitive rehabilitation was not specifically addressed. Assessing the clinical effectiveness of "different service models of multimodality/multidisciplinary post-COVID-19 syndrome rehabilitation in improving patient-reported outcomes (such as quality of life)" was listed as a key recommendation for research.
 
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through August 2023. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
A Cochrane review assessing the effectiveness of cognitive rehabilitation for recovery from stroke evaluated attention deficits following stroke (Loetscher, 2013). A 2013 update identified 6 RCTs with 223 patients (Loetscher, 2013). There was limited evidence of short-term improvement in divided attention (ability to multitask), but no indication of short-term improvements in other aspects of attention. Evidence for persistent effects of cognitive rehabilitation on attention or functional outcomes was lacking. A 2019 update identified no new trials and concluded that the effectiveness of cognitive rehabilitation for attention deficits following stroke remains unconfirmed (Loetscher, 2019).
 
Objective cognitive deficits have been reported for verbal fluency, attention, working memory, processing speed, executive functioning, learning, and memory - with no clear pattern of cognitive impairment across studies. While cognitive impairment following intensive treatment of critical illness is not a new phenomenon, the disease course of cognitive impairment experienced by individuals with post-acute sequelae of SARS-CoV-2 infection is an ongoing research priority (Vrettou, 2022; Oh, 2021; De Luca, 2022).
 
In 2009, the Veterans Administration/Department of Veterans Affairs published guidelines on the treatment of concussion and mild traumatic brain injury,78, which were updated in 2016 79,and most recently in 2021 (Department of VA/DoD, 2009; Management of Concussion-mild Traumatic Brain Injury Working Group, 2016; Department of VA/DoD, 2021). These guidelines addressed cognitive rehabilitation in the setting of persistent symptoms. The 2021 guidelines stated:
 
  • "We suggest that patients with symptoms attributed to mild traumatic brain injury [mTBI] who present with memory, attention, or executive function problems despite appropriate management of other contributing factors (e.g., sleep, pain, behavioral health, headache, disequilibrium) should be referred for a short trial of clinician-directed cognitive rehabilitation services." [Strength of recommendation: "weak for"]
  • "We suggest against the use of self-administered computer training programs for the cognitive rehabilitation of patients with symptoms attributed to mTBI." [Strength of recommendation: "weak against"]
 
A 2019 Veterans Administration/Department of Defense practice guideline on the management of stroke rehabilitation found "insufficient evidence to recommend for or against the use of any specific cognitive rehabilitation methodology or pharmacotherapy to improve cognitive outcomes" and noted "there has been very little advancement in the evidence regarding the use of specific cognitive rehabilitation strategies or techniques to improve clinical outcomes following stroke" (Department of VA/DoD, 2019).
CPT/HCPCS:
97129Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one on one) patient contact; initial 15 minutes
97130Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one on one) patient contact; each additional 15 minutes (List separately in addition to code for primary procedure)
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