If this is an ERISA plan, as the patient to bring in their SBP (Summary of Benefit Plan) and see if there are any exclusions for either the diagnosis or the treatment.
This is similar to a plan exclusion we run across for ADD/ADHD, many plans specifically exclude all coverage for both diagnosis. IF the actual SPB has this exclusion then most likely you will be billing the patient. IF NOT... then you can appeal. Your appeal would be an ERISA appeal which means you can reference the employer,and the DOL and follow proper appeal procedures for ERISA.
The APB reads like this:
Note: Coverage of outpatient cognitive rehabilitation is subject to applicable benefit plan terms and limitations for physical and occupational therapy (see CPB 0250 - Occupational Therapy Services and CPB 0325 - Physical Therapy Services). Please check benefit plan descriptions for details.
Aetna considers cognitive rehabilitation as adjunctive treatment of cognitive deficits (e.g., attention, language, memory, reasoning, executive functions, problem solving, and visual processing) medically necessary when all of the following are met:
Neuropsychological testing has been performed and neuropsychological results will be used in treatment-planning and directing rehabilitation strategies, and
The cognitive deficits have been acquired as a result of neurologic impairment due to traumatic brain injury, brain surgery, stroke, or encephalopathy, and
The member has been seen and evaluated by a neuropsychiatrist or neuropsychologist, and
The member is expected to make significant cognitive improvement (e.g., member is not in a vegetative or custodial state).
Note: Cognitive rehabilitation may be performed by an occupational therapist, physical therapist, speech/language pathologist, neuropsychologist, or a physician.
Note: According a review article on cognitive rehabilitation (Ciceron et al, 2000), rehabilitation for visuo-spatial deficits generally entails 20 1-hour sessions delivered over the course of 4 weeks. For language and communication deficits, patients usually receive 8 hours of weekly therapy, beginning at 4 weeks post-onset and continuing up to 48 weeks post-onset. Courses of cognitive rehabilitation substantially longer than these durations may be reviewed for medical necessity.
Aetna considers cognitive rehabilitation experimental and investigational for all other indications, such as the treatment of epilepsy/seizure disorders, mental retardation, cerebral palsy, dementia (e.g., from Alzheimer’s disease, HIV-infection*, or Parkinson’s disease), cognitive decline in multiple sclerosis and chronic obstructive pulmonary disease, Wernicke encephalopathy, and behavioral/psychiatric disorders such as attention-deficit/hyperactivity disorder, depression, schizophrenia, social phobia, substance abuse disorders, and pervasive developmental disorders including autism, as it has not been proven to be effective for these indications.
*Note: Cognitive rehabilitation is considered medically necessary for encephalopathy due to HIV when medical necessity criteria in section I above are met.
Aetna considers coma stimulation, also known as the "Responsiveness Program" (cognitive remediation of comatose persons), coma arousal program/therapy, sensory stimulation, and multi-sensory stimulation programs, experimental and investigational for coma and persistent vegetative state because its effectiveness has not been established..