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UM Guidelines
Cognitive Communication Disorders Rehabilitation

Ambulatory Care (AC)

BCBST last reviewed September 20, 2017*

Changed Clinical Indications to only include the following:
   
  Cognitive communication (rehabilitation) may be indicated for 1 or more of the following:
  • Traumatic brain injury

Autism is investigational (Except when Tennessee Mandate applies)

Does not apply to FEP

APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS

The Tennessee state law quoted below applies to individual policies, fully insured accounts, and self-funded accounts that are not governed by ERISA (i.e. governmental plans and church plans). Please keep in mind that it can be very difficult to determine if such a Plan is a governmental plan, (for example some utilities are governmental plans), or a church plan (for example some hospital plans are church plans.) This mandate applies to such accounts that are delivered, issued for delivery, amended or renewed on or after January 1, 2007. This mandate does not apply to self-funded accounts that are governed by ERISA unless an ERISA governed self-funded account's plan language, Explanation of Coverage (EOC), or Summary Plan Description provides coverage for these particular disorders. An ERISA governed self-funded plan's language will govern application of this policy to a plan. In addition, other federal laws will preempt this provision. In particular, the Federal Employees Program is governed by federal law and contains a provision that preempts claims and benefits similar to ERISA. The provisions of this mandate concern autism spectrum disorders and are applicable to individuals of less than twelve (12) years of age.

Tennessee Code Annotated, Title 56, Chapter 7, Part 23, was amended by adding the following languages as a new section to be appropriately designated:

(a) As used in this section, "autism spectrum disorders" means neurological disorders, usually appearing in the first three (3) years of a person's life that affect normal brain functions and are typically manifested by impairments in communication and social interaction, as well as restrictive, repetitive, and stereotyped behaviors.
(b) A contract or policy of an insurer that provides benefits for neurological disorders, whether under an individual or group health insurance policy providing coverage on an expense-incurred basis, an individual or group service contract issued by a health maintenance organization, a self-insured group arrangement to the extent not preempted by federal law or a managed health care delivery entity of any type or description shall provide benefits and coverage for treatment of autism spectrum disorders that are at least as comprehensive as those provided for other neurological disorders. These benefits and coverage for treatment shall be provided to any person less than twelve (12) years of age

References

Agency for Healthcare Research and Quality. (2012). Effective Health Care Program Comparative Effectiveness Review Number 72. Multidisciplinary postacute rehabilitation for moderate to severe traumatic brain injury in adults. Retrieved December 22, 2015 from www.ahrq.gov.

BlueCross BlueShield Association. Medical Policy Reference Manual. (3:2017). Cognitive rehabilitation (8.03.10). Retrieved June 5, 2017 from BlueWeb. (53 articles and/or guidelines reviewed)

Langenbahn, D.M., Ashman, T., Cantor, J. & Trott, C. (2013). An evidence-based review of cognitive rehabilitation in medical conditions affecting cognitive function. Archives of Physical Medicine and Rehabilitation, 94,271-286. (Level 1 evidence)

Mahan, S., Rous, R., & Adlam, A. (2017). Systematic review of neuropsychological rehabilitation for prospective memory deficits as a consequence of acquired brain injury. Journal of the International Neuropsychological Society, 2017 Jan 19:1-12. Doi: 10.1017/S1355617716001065. [Epub ahead of print]. Abstract retrieved June 5, 2017 from PubMed database.

National Institute for Health and Care Excellence. (2013). Stroke rehabilitation in adults. Retrieved December 22, 2015 from nice.org.uk/guidance/cg162.

Tennessee Code: Title 56 Insurance: Chapter 7 Policies and Policyholders: Part 23 Mandated Insurer or Plan Options: 56-7-2367. Autism spectrum disorders. Retrieved January 4, 2016 from http://www.legislature.state.tn.us/sitemap.htm.

 

 

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