Appeal type: Medical necessity
Decision: Overturned

Diagnosis: traumatic brain injury (TBI) status-post fall
Treatment: Cognitive therapy (97139 x 21)
The insurer denied coverage for: Cognitive therapy (97139 x 21)
The denial is: Overturned
This patient reportedly had a traumatic brain injury (TBI) due to severe and catastrophic injuries related to falling from a horse. The patient reportedly was medically hospitalized and then extubated and then transferred to a comprehensive rehabilitation. The patient reportedly had deficits in delayed and recognition memory, word finding, decreased verbal organization and coherence, tangential language, and mild suppression of processing speed. The patient had neuropsychological testing to have a better estimate of their neurocognitive abilities for the purpose of treatment plan development. The patient received cognitive behavioral therapy for their cognitive deficits.
  
The reviewer disagrees with the decision to deny coverage for cognitive behavioral therapy (CBT) for this patient with cognitive deficits due to a traumatic brain injury due to a severe and catastrophic injuries related to falling from a horse as this patient had a traumatic brain injury (TBI) and CBT was considered medically necessary treatment to help with their cognitive rehabilitation process. According to Archives of Physical Med Rehabilitation 2000 Cicerone, "Evidence Based Cognitive Rehabilitation: Recommendations for Clinical Practice" it states that overall, there is support existing for the effectiveness of several forms of cognitive rehabilitation for persons with TBI. This patient reportedly had a TBI due to a severe injury and had reports of specific cognitive deficits including deficits in delayed and recognition memory, word finding, decreased verbal organization and coherence, tangential language, and mild suppression of processing speed. The patient received cognitive behavioral therapy for their cognitive deficits. The patient also reportedly was taking psychotropic medications including Buspirone, Citalopram, Seroquel, Rexulti, Trazodone, and Melatonin. According to Behavioral Neurology 2019 "Psychological Intervention in Traumatic Brain Injury Patients" by Gomez-deRegil, Estrella-Castillo, and Vega-Cauich it stated that CBT is the preferred therapeutic approach for treating behavioral and emotional disturbances due to TBI. Also, according to American Psychological Association (APA) PsychNet "Cognitive Behavioral Therapy for People with  Brain Injury" by Ownsworth, Tamara, Gracey, and Fergus, it states that CBT interventions are used for rehabilitation for patients with brain injuries. Also the insurer's criteria reports that CBT rehabilitation as an adjunctive treatment for cognitive deficits is considered medically necessary treatment when: Neuropsychological testing has been performed and will be used in placing and directing rehabilitation strategies, the cognitive deficits acquired result in neurological impairment due to TBI, brain surgery, stroke, or encephalopathy, one is able to actively participate in the cognitive rehabilitation process, and that it is expected to make improvement. This patient had a neuropsychological testing and had cognitive deficits due to a traumatic brain injury, was able to participate in CBT, and it was expected to improve functioning. This patient had multiple cognitive deficits due to a TBI and there are sources supporting the use of CBT rehabilitation in treating traumatic brain injuries, so it was considered medically necessary treatment for this patient.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 
The medical necessity for cognitive therapy (97139 x 21), requested dates of service is substantiated.