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Health Insurers Deny Coverage for Cognitive Rehabilitation

Brain injury patients must often forgo cognitive rehabilitation because their insurance plan does not cover this treatment, the Wall Street Journal (WSJ) reported on Jan. 8. Patients who have had traumatic brain injury, strokes, or other brain damage often need this kind of therapy to regain functions, neurologists who specialize in rehabilitation told Neurology Today.

According to the WSJ, many insurers either do not pay for cognitive rehabilitation or they limit its scope and duration because they claim that evidence is lacking to prove that therapy improves cognition.

Cognitive rehabilitation is a broad term that can refer to therapies aimed at improving behavior, speech, memory, and attention deficits, as well as other impairments. The treatment program can involve reading, computer exercises, and card games to improve short-term memory and help patients with activities that were once second nature, such as shopping for groceries. Programs can teach patients how to use memory aides, such as pagers, notes, and handheld recorders, to keep track of tasks.

The number of people with cognitive impairment is growing because of improved medical procedures that help more people survive accidents and strokes that would have killed them decades ago, the article states.

Insurance denials for rehabilitation are an “enormous problem,” said Brent Masel, MD, a neurologist and rehabilitation specialist at the Transitional Learning Center at Galveston, TX. He said most of his patients encounter resistance from insurance companies and about half are denied coverage altogether. Fortunately, in Texas, the state uses a percentage of fines collected for misdemeanors and felonies to pay for rehabilitation services for patients who request them. Once patients overcome post-traumatic amnesia, the ideal approach is to start therapy right away, Dr. Masel said. But this can be compromised by the fact that the state's program has a waiting list, meaning time to treatment can vary from a few months to one year, he added.


Data on the effectiveness of cognitive rehabilitation, however, are scarce because each brain injury is different, making it difficult to conduct large, standardized studies, Dr. Masel said.

However, a 2005 article reviewed 87 studies published from 1998 through 2002 and concluded that there is sufficient evidence to support the use of rehabilitation therapy for stroke and traumatic brain injury (Arch Phys Med Rehabil 86(8):1681–1692). “The overall analysis …reveals a differential benefit in favor of cognitive rehabilitation in 37 of 47 comparisons, with no comparison demonstrating a benefit in favor of the alternative treatment condition,” the authors wrote.


Dr. Brent Masel said most of his patients encounter resistance from insurance companies and about half are denied coverage altogether.

One of the studies reviewed in the article reported that a portable pager can help people with brain injury reduce everyday failures of memory and planning (J Neurol Neurosurg Psychiatry 2001;70:477–482). Patients learned to use the pager to remind them to keep track of certain tasks, such as self-medication and appointments. More than 80 percent who completed the 16-week trial were significantly more successful in carrying out everyday activities when using the pager in comparison with the baseline period.

Anna M. Barrett, MD, told Neurology Today that researchers need to improve the definition of progress among heterogenous groups of patients so that they “can show a benefit that insurance companies can understand.” Study results are sometimes skewed because some patients respond better to treatment than others, she said, making it difficult for insurance companies to define whether the rehabilitation program is effective. Dr. Barrett is an associate professor of physical medicine and rehabilitation, and neurology and neurosciences at the University of Medicine and Dentistry of New Jersey, and director of stroke rehabilitation research at the Kessler Medical Rehabilitation Research and Education Center.

In an editorial, Dr. Barrett and Leslie J. Gonzalez Rothi, PhD, claim this is one of the challenges to moving basic discovery in stroke rehabilitation toward large-scale, systemic clinical studies (J Rehabil Res Dev 2006;43(3):7–9). “As practitioners apply a developed treatment, they may discover that the results do not generalize or do not apply to certain patients,” they wrote. “Systematic investigation of these particular patients will give rise to data-refining clinically valid practice.” These understudied groups may include patients with multiple chronic medical problems, women, members of ethnic, racial, and cultural minorities, rural dwellers, and the poor. “Unless appropriate secondary analyses are performed, this disparity in response may go undetected and the trial reported as lacking any treatment benefit.”

Dr. Barrett said another factor influencing insurance denials is that patients and doctors tend to measure progress on a different time scale than insurance companies. “Insurance companies have to be encouraged to look at what's best, and efficient, for society rather than individual cases,” she said. In addition, “they are driven by short-term results.”

Insurance companies need to understand that “brain injury is not an event,” Dr. Masel said. “It's not like you break a bone, put it in a cast, and after three months, give or take, everything is ok. Brain injury is the beginning of a disease that can last forever.”

Explaining to insurers that a patient could get back to work with a therapy such as driving training, can convince them that it is worth covering, according to Dr. Barrett. Covering cognitive rehabilitation saves society money and resources because it helps brain-injured people become more independent and less likely to rely on government services, she said.

But Kenneth M. Heilman, MD, the James E. Rooks Jr. Distinguished Professor of Neurology & Health Psychology at the University of Florida, has a more rigid view. “Insurance companies do not always support what is best for their clients' health; they do what makes them money,” he said. The fact that cognitive rehabilitation is “very labor intensive,” also doesn't attract coverage, he said.

Dr. Heilman, who is also program director and chief of the North Florida/South Georgia Veterans Administration Medical Center, pointed to a case study conducted by Veterans Affairs (VA) researchers of a 77-year-old woman who regained vital communication skills after enrolling in a speech rehabilitation program 54 years after she experienced a massive left-hemisphere ischemic infarction (J Rehabil Res Dev 2006;43(3):323–336). Led by Diane Kendall, PhD, the team administered a total of 74 hours of phonological treatment over 6 months. The treatment took place at the VA Center one day a week and in the patient's home two to three days a week. They found that the unplanned, informal communication between the patient and her therapist in the patient's home was probably more effective than the VA's structured program. During these conversations at home, the speech therapist offered the patient little support and instead pressed her to communicate on her own when she experienced anomia.

“This finding is consistent with the concept that speech therapy conducted long after stroke can engage normal learning mechanisms, which may remain substantially intact despite a focal brain lesion,” they wrote.

Dr. Heilman said the patient can now converse fluently and comprehend complex sentences. “Can you imagine? If we knew as much then as we know now perhaps she wouldn't have had to suffer all those years with this disability,” he said.


While there are initial obstacles, neurologists do have leverage in helping patients obtain coverage, Dr. Masel said. One way is to get the patient's family involved so that they contact the insurance company and human resources department of their relative's company to convince them to provide coverage. Physicians can also contact the medical director of the insurance company and explain what they hope to accomplish and how long it will probably take. “You need to roll up your sleeves,” he said. “It takes a little work.”

Dr. Barrett said that about 60 to 70 percent of her patients are denied some portion of coverage initially, but after pleading with their insurance companies about the treatment's benefits, only about 10 to 20 percent are still left without any coverage.

“When I was in the private practice of neurology I was skeptical about a lot of this as most neurologists are,” Dr. Masel said. “But it really does make a difference. You can really change lives after a brain injury.”


Many insurance companies deny coverage for cognitive rehabilitation because they claim there is insufficient evidence showing that it is effective. But some neurologists say the therapy is necessary for brain-injured patients to regain functions.


• Cicerone KD, Dahlberg C, Malec JF, et al. Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 1998 Through 2002. Arch Phys Med Rehabil 86(8):1681–1692.
    • Wilson BA, Emslie HC, Quirk K, et al. Reducing everyday memory and planning problems by means of a paging system: a randomized control crossover study. J Neurol Neurosurg Psychiatry 2001;70:477–482.
    • Gonzalez Rothi LJ, Barrett AM. Treatment innovation in behavioral rehabilitation of stroke: Removing limits on recovery. J Rehabil Res Dev 2006;43(3):7–9.
    • Kendall DL, Nadeau SE, Conway T, et al. Treatability of different components of aphasia-Insights from a case study. J Rehabil Res Dev 2006;43(3):323–336.