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.