BIAA Applauds Victory for Coverage of Cognitive Rehabilitation

The Brain Injury Association of America (BIAA) applauds the recent decision by Maximus®, a national leader in independent health appeals services, to overturn a denial by Blue Cross Blue Shield of Mississippi for cognitive rehabilitation for James Butler of Madison, Miss. Mr. Butler sustained a stroke in October 2010.

The external analysis states: “In a review of the literature concerning patients that receive cognitive rehabilitation, the conclusion reached is that ‘there is sufficient information to support evidence protocols and implement empirically-supported treatments for cognitive disability after traumatic brain injury and stroke.’ This patient’s neurorehabilitation is consistent with established programs in the treatment of chronic stroke and the literature indicates that cognitive rehabilitation is not experimental or investigational in nature. The use of cognitive rehabilitation is clearly medically necessary and is consistent with good medical practice for this diagnosis.”

The review concludes, “Cognitive rehabilitation meets the health plan’s definition of ‘medical necessity’ as it is appropriate with regard to current standards of good medical practice and is not solely for the convenience of the member or his provider.”Through a year-long appeals process, the decision of the external review, which was just handed down, was to overturn the denial.

The potential use of this precedent for people who have sustained a traumatic brain injury or stroke is very important.

“Coverage for cognitive rehabilitation has been a centerpiece of BIAA’s advocacy efforts for the past six years,” said Susan H. Connors, president and CEO. “BIAA will continue its efforts to bring attention to the nationwide disparities in access to medically necessary treatment, including cognitive rehabilitation, for individuals with brain injury.”

According to Ms. Connors, “Getting a treatment (in this case, cognitive rehabilitation) acknowledged as a viable treatment is only the first hurdle in accessing care. Public and private payers of all types will cover a service if and only if all other conditions are met, including if the treatment is deemed ‘medically-necessary.’” Medicare and Medicaid have no national policy for brain-trauma rehabilitation, Connors says. Private insurers’ coverage varies considerably. Most say they cover cognitive therapy and other brain-injury services, but each policy carries limitations.

The benefits of cognitive rehabilitation have been discussed in more than 700 published research studies and are evident in positron emission tomography (PET) scans and other neuroimaging techniques in both human beings and animal models. Numerous scientific organizations and professional associations have adopted treatment guidelines or position statements in support of cognitive rehabilitation for individuals with brain injury. Federal and state governments have acknowledged the value of cognitive rehabilitation by allocating taxpayer funds for services. Lawmakers in selected states have required private insurance companies to include cognitive rehabilitation and related therapies in their accident and health insurance policies. Because of the growing body of testimonials and evidence-based literature, more and more payers are covering cognitive rehabilitation treatment.

Many patients and their families do not realize rehabilitation services are available. “Patients have no idea,” said Dr. Brent Masel, national medical director for BIAA. “Insurance companies don’t want people to know that there’s another step after they leave the hospital.”

Mary Hawkins Butler, wife of James Butler, fought tirelessly on her husband’s behalf. She recognized this decision could also benefit many, many more people.  Ms. Butler said, “The mission was that something good would come out of this for others. I hope this ruling is just the beginning. No one with a brain injury should be put in ‘storage’ to live out their life because they are not allowed the coverage that would offer the rehabilitation to restore their dignity and give them the quality of life they deserve,” as her husband has been able to achieve. “I hope the house of cards that prevents people from getting  cognitive rehabilitation from their insurance providers comes tumbling down because it is so wrong and such an injustice to the people who have already experienced such a loss to not have an avenue of hope.”

Click here for the full press release.
Click here the timeline of BIAA’s advocacy efforts in support of cognitive rehabilitation services.