Medical Necessity

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).

Covered Services

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.

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.

Otherwise covered services that incidentally address cognitive deficits as factors involved with the restoration of lost neuromuscular functions are covered.

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.

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.

Maintenance Programs

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.

Rehabilitative Programs

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.

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.

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.
• The individual is willing and able to actively participate in the treatment plan.
• 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.

Services Not Covered

Community and work integration training, such as listed in Current Procedural Terminology (CPT) procedure code 97537 is excluded.

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.

Coma stimulation. Activities of external stimulation intended to arouse a beneficiary from a coma.

Programs. Standard bundles of services (programs) as an all-inclusive priced unit or services.

• 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.

Sensory integration therapy (CPT procedure code 97533) which may be considered a component of cognitive rehabilitation is unproven.

Self-administered computer-based CRT is unproven.

Services provided to address disorders or conditions (e.g., speech, language, or communication) resulting from occupational or educational deficits.

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.

Reference

TRICARE Policy Manual 6010.60-M

Chap. 7 § 18.1