Even so, experts say there is limited evidence about its effectiveness, the number of sessions that are most effective and whether inpatient care is superior.
While some people have improved their thinking and reasoning skills years after brain injuries, most neurological recovery tends to occur in the first 18 to 24 months, said Ruth Gromek, who manages outpatient brain injury rehab services at Hennepin County Medical Center.
“Doesn’t mean that is the end-all,” Gromek said. “But the sooner the recovery comes, I guess, the better.”
All of which creates urgency for Cizek’s family.
Her cognitive skills return in fragments. This spring, she could write the word triangle in her familiar handwriting, but couldn’t identify one from a picture of various shapes.
Now she is able to carry out daily routines — like slipping on headphones and running a mile or two at a nearby track. It is a rare opportunity for calm and freedom in a world in which she can’t drive and is constantly monitored.
“I want to get my independence back,” she said.
One challenge, her father said, is that Cizek feels healthy, but lacks the foresight to understand why she still needs therapy to get on with her life. “Her goal is [going back to] KU, but she doesn’t know how to get there,” he said. “She thinks she can get out of bed tomorrow and go.”
Insurers are cautious
The Brain Injury Association of America believes there should be no arbitrary caps on days of cognitive rehab because treatment of patients is so individualized. Texas has mandated that insurers cover the services, and lawmakers in California and other states have considered a similar step.
But insurers have been cautious. In the absence of clear research showing the benefits of cognitive rehab, they don’t want to pay for an expensive service that might not work.
A month at Quality Living, according to the Cizeks, costs $27,000.
Bloomington-based HealthPartners has a general policy of covering up to 10 visits of initial, outpatient therapy, and then will consider additional visits if there is evidence that the patient is making progress toward specific cognitive goals.
Most insurers do not cover appointments once progress has stopped — or so-called “maintenance” appointments to simply preserve a patient’s level of brain function.
Insurers are updating their policies according to the latest research, said Eileen Smith, a spokeswoman for the Minnesota Council of Health Plans. The HealthPartners recommendation, updated last month, is an example — its limits aren’t based on an arbitrary number of visits but on whether a doctor believes additional therapy will yield continued improvement.
“It’s not a financial limit, but is based on goals and objectives and improvement,” Smith said.
The Cizek family declined to identify their insurance company, a national carrier, because they don’t want bad publicity to taint any appeals they might make.
Cizek has no memory of “the incident,” as she calls it. Too many questions about the future or too many people in a crowd cause her stress and she slips away for a quiet walk.