Clinician Battles Medicare and Wins

After a two-and-a half year crusade, Dr. Marie DiCowden, founder and director of Biscayne Institutes of Health and Living, Inc., in Miami, Florida, has won the right to receive reimbursement from Medicare for cognitive training for brain-injured and neurologically impaired clients. Blue Cross Blue Shield of Florida, the administering agent for Medicare, had refused payment for cognitive training, stating that the efficacy of cognitive rehabilitation after traumatic brain injury has not been established. They also added a requirement that they would only reimburse these services if "drastic improvement" occurred.

The CPT code 97532* for cognitive training ("development of cognitive skills to improve attention, memory, problem solving, direct patient contact by the provider, each 15 minutes") has been approved by Medicare for use by all practitioners including clinical psychologists and speech language pathologists since 1995. However, carriers in different states may set their own policies related to this code.

At the beginning of Dr. DiCowden's appeal, APA wrote a letter reminding the carrier that the NIH Consensus Statement on TBI supports the inclusion of cognitive training in a comprehensive rehabilitation program and refers to documentation of its success. Regarding the "drastic improvement" requirement, an expert witness, Dr. William Benda, stated, "By that criteria, a ... patient who undergoes surgery and dies on the table has not experienced drastic improvement.. I believe this criteria was developed specifically to deny benefits to patients."

Dr. DiCowden's victory may provide inspiration to clinicians wishing to offer cognitive training services, and it can help educate the public on the importance of cognitive training. For more detailed information on this story, see "Winning One with Medicare" by Kathryn Foxhall, Monitor on Psychology, (pp. 64-65), September, 2001. American Psychological Association.

Reprinted from The BrainTrain Bugle,
Volume 5, Issue 1, September, 2001

* Previous CPT code was 97770. Note that CPT codes change over time and clinician's should check with the insurance providers for the most recent CPT codes.