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) (Current Procedural Terminology (CPT)
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 CPT 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 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.