2.0 POLICY
2.1 Section
704 of the National Defense Authorization Act for Fiscal Year 2002
(NDAA FY 2002), Public Law 107-107, states the Department “may”
provide any rehabilitative therapy to improve, restore, or maintain
function, or to minimize or prevent deterioration of function, of
a patient when prescribed by a physician. Any therapy for the purpose
of improving restoring, maintaining, or preventing deterioration
of function, must be medically necessary and appropriate medical
care. The rehabilitation therapy must be rendered by an authorized
provider, necessary to the establishment of a safe and effective
maintenance program in connection with a specific medical condition,
provided at a skilled level and must not be custodial care or otherwise
excluded from coverage (e.g., exercise or able to be provided at
a non-skilled level).
2.2 Services which have been demonstrated
to be capable of reliably confirming the severity of impaired function
attributable to a physical impairment may be cost-shared when medically
necessary and appropriate.
2.3 Services or items which have
been demonstrated to be usually capable of reducing or arresting the
severity of impaired function attributable to a physical impairment
may be cost-shared when medically necessary and appropriate.
2.4 Otherwise
covered services that incidentally address cognitive deficits as
factors involved with the restoration of lost neuromuscular functions
are covered.
2.5 Otherwise covered services such as diagnostic
or assessment tests and examinations that are prescribed specifically
and uniquely to measure the severity of cognitive impairment are
covered.
2.6 The following therapies and services rendered
by an employee of an authorized institutional provider may be cost-shared
when part of a comprehensive rehabilitation treatment plan:
• Physical
therapy.
• Rehabilitation
counseling.
• Mental
health services.
• Speech pathology
services.
• Occupational
therapy.
2.7 The specialized knowledge
of a skilled provider may be required to establish a maintenance program
intended to prevent or minimize deterioration caused by a medical
condition. Establishing such a program is a skilled service. The
initial evaluation of the patient’s needs, the designing by a skilled
provider of a maintenance program which is appropriate to the capacity
and tolerance of the patient, the instruction of the patient or
family members in carrying out the program and infrequent evaluations
may be required.
2.8 While
a patient is under a restorative rehabilitative therapy program,
the skilled provider should reevaluate his/her condition when necessary
and adjust any exercise program that the patient is expected to
carry out himself/herself or with the aid of family members to maintain
the function being restored. Consequently, by the time it is determined
that no further restoration is possible, i.e., by the end of the
last restorative session, the provider will have already designed
the maintenance program required and instructed the patient or family
member in the carrying out of the program. Therefore, where a maintenance
program is not established until after the restorative rehabilitative
therapy has been completed, it would not be considered medically
necessary and appropriate medical care and would be excluded from
coverage.
2.9 Once a patient has reached the point where
no further significant practical improvement can be expected, the
skills of an authorized provider will not be required in the carrying
out of an activity/exercise program required to maintain function
at the level to which it has been restored. The services of a skilled
provider in designing a maintenance program will be covered, carrying
out the program is not considered skilled care, medically necessary
or appropriate medical care consequently such services are not covered.
2.10 Services
that are palliative in nature are not considered medically necessary
and appropriate medical care and are not covered. These services
generally do not require physician judgement and skill for safety
and effectiveness.
2.11 Cognitive Rehabilitation Therapy
(CRT) (CPT procedure code 97127) for
the treatment of cognitive deficits due to Acquired Brain Injury
(ABI) (Traumatic Brain Injury [TBI] or stroke) is proven and may
be covered on an outpatient basis when the following requirements
are met:
• Therapy
provided by an authorized individual TRICARE provider.
• A
documented cognitive impairment with related compromised functional
status exists. (See
paragraph 2.1 medically necessary and appropriate.)
• The
individual is willing and able to actively participate in the treatment
plan. (See
paragraph 2.1, must not be custodial care.)
• For
mild TBI and stroke, a short term trial of CRT which focuses on
time-limited, measurable goals related to reducing activity limitations
and improving activity participation may be undertaken to assess
whether the patient would benefit from strategy training and memory
compensation techniques. A goal-based, functional re-assessment
to document treatment response shall be completed and submitted
no later than one month after treatment for any further authorization
of care. (See
paragraph 2.8, the skilled provider should
reevaluate his/her condition when necessary.)
3.0 EXCLUSIONS
3.1 Community
and work integration training, such as listed in Current Procedural
Terminology (CPT) procedure code 97537 is excluded.
3.2 Vocational
rehabilitation. Educational services intended to provide a beneficiary
with the knowledge and skills required for the performance of a
specific occupation, vocation, or job.
3.3 Coma stimulation. Activities
of external stimulation intended to arouse a beneficiary from a coma.
3.4 Programs.
Standard bundles of services (programs) as an all-inclusive priced
unit or services.
Note: Services rendered during such a program
encounter must be itemized and each reviewed to determine if rendered
by an authorized individual professional provider, if it is a covered
benefit, and whether it is medically necessary and appropriate.
3.5 Sensory
integration therapy (CPT procedure code 97533) which may be considered
a component of cognitive rehabilitation is unproven.
3.6 Self-administered computer-based
CRT is unproven.
3.7 Services provided to address
disorders or conditions (e.g., speech, language, or communication)
resulting from occupational or educational deficits.
3.8 Low Level Laser Therapy (LLLT) (also known
as low level light therapy or cold laser therapy) for treatment
of soft tissue injuries, pain or inflammation is unproven.