TBI: Many Patients Do Not Get the Care Gabrielle Giffords Has

Many insurance companies deny latest in tramuatic brain injury treatment.

ByABC News
March 3, 2011, 12:05 PM

March 4, 2011 — -- Nearly three months after she was shot in the head, Arizona Rep. Gabrielle Giffords is progressing well in her rehabilitation at TIRR Memorial Hermann in Houston, where, according to her doctors, she is receiving a combination of physical, cognitive and speech rehabilitation. They say she is vocalizing more and is able to mouth the words to songs.

While Giffords is getting top-flight care at a facility that specializes in rehabilitation after major brain injuries, many patients get nothing close to it. The fine print in many health plans -- including Medicare and Tricare, which serves U.S. military members -- excludes coverage of certain types or even complete rehabilitation for thousands of patients with traumatic brain injuries, or TBIs.

"Cognitive rehabilitation services designed to improve cognitive functioning after a brain injury are not supported by reliable scientific evidence of efficacy," according to a 2008 Tricare coverage manual.

However, the manual stated that cognitive rehabilitation is subject to coverage if cognitive rehabilitation is combined with other forms of rehabilitation and "not billed as a separate service."

But the Brain Injury Association of America, a non-profit group that advocates on behalf of people with brain injuries, says studies have shown that cognitive rehab is very effective.

"We put out a call for cognitive rehabilitation as a six-year program," said Susan Connors, president of the Brain Injury Association.

Experts say that despite the promising research, insurance companies provide little coverage for long-term rehabilitation, leaving many TBI patients with almost nowhere to turn to get the services they need for recovery.

Monique Pomerleau is one woman whose family says she is in exactly this situation. Pomerleau, a 37-year-old mother of three from southern California, suffered a TBI after a serious car accident one year ago on Valentine's Day.

"She was ejected through the window of her car, and was in intensive care for 19 days," said Tom Pomerleau, Monique's father. "At one point, they wanted me to pull the plug, but we got signs she was going to make it."

After also suffering a broken collarbone, numerous infections, and, most seriously, hydrocephalus -- the buildup of cerebrospinal fluid on the brain -- Monique wound up spending seven months in what her father described as a convalescent home. He said that facility couldn't help her get the rehabilitation services she needed.