MEDICAL POLICY

POLICY
RELATED POLICIES
POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Sensory and Auditory Integration Therapy

Number 8.03.500

Effective Date November 10, 2014

Revision Date(s) 11/10/14; 04/14/14; 05/13/13; 04/10/12; 03/08/11; 02/09/10; 02/10/09; 10/14/08; 05/13/08; 02/13/07; 02/14/06; 10/12/04; 05/13/03; 01/23/01; 12/21/00; 06/27/00

Replaces 8.03.13

Policy

[TOP]

Sensory Integration Therapy

Sensory integration therapy (SIT) may be considered medically necessary as a treatment for children when specifically and only focused on treating 1 or more of the following sensory integration conditions or disorders:

  • Balance and proprioception difficulties that are pathological for a child's age and developmental stage
  • Feeding intolerance that is pathological for a child's age and developmental stage
  • Tactile intolerance that is pathological for a child's age and developmental stage

Sensory integration therapy is considered investigational for all other conditions or disorders.

Auditory Integration Therapy

Auditory integration therapy (AIT) is considered investigational.

Related Policies

[TOP]

8.03.503

Occupational Therapy

Policy Guidelines

[TOP]

Sensory Integration Therapy

Sensory integration therapy (SIT) is provided by qualified occupational and sometimes physical therapists, who are specifically certified in sensory integration therapy. A qualified provider is one who is licensed and performs within the scope of his/her licensure or practice.

SIT is usually provided in a one-to-one setting. These sessions are often provided as part of a comprehensive occupational therapy or cognitive rehabilitation therapy and may last for more than 1 year.

Definition of Terms

  • Balance and proprioception difficulties – proprioception is the sense of position, posture, movement and velocity of the body and body parts. Also the perception of space. Examples of impaired sensory status may include sensory-motor problems like extreme clumsiness or lack of coordination, flaccid muscles when moving or sensing movement (limp, “rag doll” appearance), or muscle rigidity, atypical reaction to having people or things in the child’s personal space or in close proximity.
  • Feeding intolerance – is an atypical response to the sensation of food or fluids in the mouth, the temperature of food or fluids, the sensation of chewing, or the teeth touching. Examples of impaired sensory status may include an extreme refusal (aversion) to eat/drink by expelling (spitting) or packing (pocketing) food, eating very selectively by type or texture of food.

Tactile intolerance – is an atypical response to the physical sensation of touch. Examples of impaired sensory status may include a disproportionate reaction to physical contact (touch); intolerance to wearing clothes, inability to tolerate the feel (sensation) of and the texture of fabrics/surfaces, intolerance to being touched by others.

Auditory Integration Therapy

  • is usually provided in 2 half-hour sessions per day separated by at least 3 hours, over 10 consecutive days, during which patients listen to recordings

iLS Total Focus System

Integrated Learning Systems (iLS) distributes the iLS Total Focus System, described as an educational tool to “train the neurological pathways needed for daily functioning. The combined activities have a global effect on the brain and central nervous system, influencing the following systems and their function: auditory, visual, vestibular, motor cognitive and emotional.” The iLS Focus system, designed for home use, consists of programs loaded onto an Apple iPod, headphones and other accessories.

iLS systems are educational devices, not durable medical equipment (DME), and therefore are not a covered service/product.

Coding

CPT

97533

Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by provider, each 15 minutes

(This code may also be used for auditory integration therapy.)

Description

[TOP]

Sensory integration (SIT) therapy is a treatment of developmental disorders in patients with established dysfunction of sensory processing, e.g., children with autism, attention-deficit/hyperactivity disorder, brain injuries, fetal alcohol syndrome, and neurotransmitter disease.

Auditory integration therapy (AIT) uses gradual exposure to certain types of sounds to improve communication in a variety of developmental disorders, particularly autism.

Background

Sensory Integration Therapy

The goal of sensory integration (SI) therapy is to improve the way the brain processes and adapts to sensory information, as opposed to teaching specific skills. Therapy usually involves activities that provide vestibular, proprioceptive, and tactile stimuli, which are selected to match specific sensory processing deficits of the child. For example, swings are commonly used to incorporate vestibular input, while trapeze bars and large foam pillows or mats may be used to stimulate somatosensory pathways of proprioception and deep touch. Tactile reception may be addressed through a variety of activities and surface textures involving light touch.

Two organizations currently offer certification for sensory integration therapy:

  • Integration International (SII), a non-profit branch of the Ayres Clinic in Torrance, CA.
  • Psychological Services, a private organization that has a collaborative arrangement with University of Southern California (USC) to offer sensory integration training through USC’s department of Occupational Services.

Auditory Integration Therapy

Auditory integration therapy (also known as auditory integration training, auditory enhancement training, and audio-psycho-phonology) is another method that relies on gradual exposure to sound to which individuals are sensitive, based on having individuals listen to music that has been modified to remove frequencies to which the individual is hypersensitive. Although several methods have been developed, the most widely-described is the Berard method, which involves 2 half-hour sessions per day separated by at least 3 hours, over 10 consecutive days, during which patients listen to recordings. Auditory integration training has been proposed for individuals with a range of developmental and behavioral disorders, including learning disabilities, autism spectrum disorders, pervasive developmental disorder, attention deficit and hyperactivity disorder. Other methods include the Tomatis method, which involves listening to electronically-modified music and speech, and Samonas Sound Therapy, which involves listening to filtered music, voices, and nature sounds.1

Regulatory Status

Sensory integration therapy is a procedure and, as such, is not subject to regulation by the US Food and Drug Administration (FDA).

There are no devices designed to provide auditory integration therapy that have clearance for marketing from FDA.

Scope

[TOP]

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage.

Benefit Application

[TOP]

For contracts that have a neurodevelopmental benefit, this service may qualify as Neurodevelopmental/Habilitative therapy. Otherwise, eligible services may be reimbursed under the Rehabilitation benefit.

Rationale

[TOP]

This policy was developed in June 2000 based on a TEC Assessment. Since that time, the policy has been reviewed on a regular basis using the MEDLINE database. The most recent literature search was conducted through September 2014. Following is a summary of the key literature.

Sensory Integration Therapy

A 2000 TEC Assessment compared the outcomes of sensory integration therapy with that of standard occupational/physical therapy among children with autism, mental retardation, or learning disabilities. The TEC Assessment offered the following observations and conclusions:

  • TEC Assessment identified only one study that focused on the use of sensory integration therapy in patients with autism. The study included only five children and there was no control group.
  • TEC Assessment identified 3 studies that focused on patients with mental retardation. The three studies were inconsistent in their results regarding the superiority of sensory integration therapy. Furthermore, the one study that did employ adequate random assignment of children to groups and used assessors who were blinded to the children’s treatment groups found no differences between sensory integration therapy and standard therapy.
  • TEC Assessment identified eleven studies that in total included more than 600 learning disabled children. Among the studies that used random assignment and blinded assessors, a very clear and consistent pattern emerged. The evidence suggested that sensory integration therapy was not superior to conventional therapy, and in many cases was not even demonstrably superior to any treatment at all. A 1999 meta-analysis also reported that the most recent studies of sensory integration therapy did not seem to support its effectiveness.

In a 2003 controlled trial study of 45 children with Down’s syndrome divided into three treatment groups (sensory integrative therapy alone, vestibular stimulation combined with sensory integrative therapy, and neurodevelopmental therapy), Uyanik and colleagues reported greater improvements in outcomes in the vestibular stimulation with sensory integrative therapy group and in the neurodevelopmental therapy group when compared to the sensory integrative therapy alone group. Outcomes assessed were the Ayres Southern California Sensory Integration Test, Pivot Prone Test, Gravitational Insecurity Test, and Pegboard Test along with physical assessment. The authors concluded all methods of treatment should be considered when planning rehabilitation therapies for children with Down’s syndrome even though sensory integrative therapy alone was not shown to be superior to the other therapy groups.

In 2005, Schaaf and Miller reviewed the current state of the evidence to support sensory integration theory as it is used in occupational therapy practice for children with developmental disabilities. They suggest that consensual knowledge and empirical research are needed to further elucidate the theory and its utility for a variety of children with these developmental disabilities. They note that parents of children with autism and other developmental disabilities have anecdotally noted the utility of sensory integration therapy for helping their children function more independently. Key limiting factors to research include lack of funding, paucity of doctorate trained clinicians and researchers in OT, and the inherent heterogeneity of the population of children affected by sensory integrative dysfunction.

In a 2007 article, authors Myers and Johnson explain that Sensory Integration (SI) can sometimes be used alone or as part of a broader program of occupational therapy for children with Autism Spectrum Disorders (ASD). It is common for these children to have unusual sensory responses. “The goal of SI is not to teach specific skills or behaviors but to remediate deficits in neurologic processing and integration of sensory information to allow the child to interact with the environment in a more adaptive way.” Additionally, they note that there is not good evidence that these symptoms differentiate ASDs from other developmental disorders, and that the efficacy of SI therapy has not been objectively demonstrated.

In 2010, May-Benson and Koomar published a systematic review of SI therapy. The review identified 27 research studies (13 Level-l randomized trials) that met the inclusion criteria. Most of the studies had been performed in children with learning or reading disabilities; there were 2 case reports/small series on the effect of sensory integration therapy in children with autism. The review concluded that although the SI approach may result in positive outcomes, findings may be limited because of small sample sizes, variable intervention dosage, lack of fidelity to intervention, and selection of outcomes that may not be meaningful or may not change with the treatment provided.

Another pilot study, reported in 2011, randomized 37 children with a sensory processing disorder (21 with autism and 16 with pervasive developmental disorder not otherwise specified) to SI interventions or to fine motor interventions (18 treatments over 6 weeks). Blinded evaluation at the conclusion of the intervention found no significant difference between the 2 groups on the Quick Neurological Screening Test (QNST) or sensory processing scores except for Autistic Mannerisms (e.g., stereotyped or self-stimulatory behavior) subscale. The SI group demonstrated greater improvement than the fine motor group on individualized Goal Attainment Scaling. Post-hoc analysis found that more children in the SI group were able to complete parts of the standardized QNST after the intervention. This finding is limited by the post-hoc analysis and the difference in the 2 groups at baseline.

In 2012 Addison et al compared the effects of escape extinction (EE) plus noncontingent reinforcement (NCR) with sensory integration therapy (SIT) as a treatment for the feeding problems of 2 children. Though this was a micro-study the discussion of SIT provides insight into how the brain integrates sensory information to produce end-product behavior. “According to these sources (cited in the article), treatment involves modification of the child’s sensory diet, which is the sensory input needed by an individual to organize sensory information effectively…this might include rhythm and music activities, proprioceptive activities, heavy work, and sensory modulation techniques”.

In 2014, Schaaf et al. reported results from a randomized trial of a manualized intervention for sensory difficulties in children with autism. The study enrolled 32 children from a convenience sample of eligible families with children aged 4-8 who had a diagnosis of autism and demonstrated difficulty processing and integrating sensory information as measured by the Sensory Profile or the Sensory Integration and Praxis Test. Subjects were randomized to usual care or to an intervention described as following the principles of sensory integration outlined by Ayres. The intervention was delivered by 3 licensed occupational therapists with experience working with children with autism spectrum disorders. The primary outcome was Goal Attainment Setting, a systematic process for identifying goals that are relevant to individuals and their families that has been used for evaluation of patients with autism. Sample goals include, “Improve auditory process as a basis for sleeping through the night without getting out of bed for 7–8 h per night,” and “Decrease oral sensitivity and will try 5 new foods.” Each goal is associated with a scale for level of attainment. For the primary outcome, the experimental group had a significantly higher goal achievement score than the control group (mean 56.53 [N=17] vs 42.72 [N=14], P=0.003). Change in functional skills did not differ significantly between groups, but experimental group subjects had significantly greater improvements in self-care caregiver assistance (P=0.008) and social function caregiver assistance (P=0.039). The groups did not differ in terms of autistic or adaptive behaviors. A strength of this study is its use of a protocolized intervention and its attempt to use an outcome measure relevant to patients and families. However, further replication in a larger sample of patients and further validation of the Goal Attainment Setting score process.

Practice Guidelines and Position Statements

The American Academy of Pediatrics (AAP) stated in 2007 guidance that “the efficacy of SI [sensory integration] therapy has not been demonstrated objectively.” The guidance document on management of children autism spectrum disorders is available online; see reference section.

A 2012 policy statement by the AAP on SI therapies for children with developmental and behavioral disorders states that “occupational therapy with the use of sensory-based therapies may be acceptable as one of the components of a comprehensive treatment plan. However, parents should be informed that the amount of research regarding the effectiveness of sensory integration therapy is limited and inconclusive.” The AAP indicates that these limitations should be discussed with parents, along with instruction on how to evaluate the effectiveness of a trial period of SI therapy

In 2009, the American Occupational Therapy Association (AOTA) stated that the AOTA recognizes sensory integration (SI) as one of several theories and methods used by occupational therapists and occupational therapy assistants working with children in public and private schools to improve a child’s ability to access the general education curriculum and to participate in school related activities.

In 2011, the AOTA published evidence-based occupational therapy practice guidelines for children and adolescents with challenges in sensory processing and sensory integration. AOTA gave a level C recommendation for sensory integration therapy for individual functional goals for children, for parent-centered goals, and for participation in active play in children with sensory processing disorder, and to address play skills and engagement in children with autism. A level C recommendation is based on weak evidence that the intervention can improve outcomes, and the balance of the benefits and harms may result either in a recommendation that occupational therapy practitioners routinely provide the intervention or in no recommendation because the balance of the benefits and harms is too close to justify a general recommendation. Specific performance skills evaluated were motor and praxis skills, sensory-perceptual skills, emotional regulation, and communication and social skills. There was insufficient evidence to provide a recommendation on sensory integration for academic and psychoeducational performance (e.g., math, reading, written performance).

Section Summary

The most direct evidence related to outcomes from sensory integration therapy comes from small randomized trials. Some of these studies have demonstrated statistically significant improvements on subsets of the outcomes measured. Therefore, sensory integration therapy may be considered medically necessary only when focused on treating the sensory disorders listed in the policy statement.

Auditory Integration Therapy

Although auditory integration therapy has been proposed as a therapy for a number of neurobehavioral disorders, the largest body of evidence on auditory integration therapy relates to its use in autism spectrum disorder.

Several systematic reviews have evaluated the evidence related to auditory integration therapy for autism spectrum disorders. A 2011 Cochrane review evaluated auditory integration training along with other sound therapies for autism spectrum disorders.1 Included were 6 randomized controlled trials of auditory integration therapy and one of Tomatis therapy, involving a total of 182 subjects aged 3 to 39 years. For most of the studies, the control condition consisted of listening to unmodified music for the same time as the active treatment group. Allocation concealment was inadequate for all studies, and 5 of the trials had fewer than 20 participants. Meta-analysis could not be conducted. Three studies did not demonstrate any benefit of auditory integration therapy over control conditions, and 3 studies had outcomes of questionable validity or outcomes that did not achieve statistical significance. The review found no evidence that auditory integration therapy is an effective treatment for autism spectrum disorders; however, evidence was not sufficient to prove that it is not effective.

A 2010 systematic review of therapies for autism evaluated the evidence for auditory integration training in the treatment of autism.14 The author identified a 2002 systematic review (an early version of the 2011 Cochrane review by Sinha et al referenced above), which identified no RCTs meeting the author’s inclusion criteria, and no subsequent RCTs or cohort studies comparing auditory integration therapy to usual care.

In 2009, Rossignol conducted a systematic review of novel and emerging treatments for autism spectrum disorders, including auditory integration therapy.15 The authors identified one 3-month double-blind controlled study of auditory integration therapy in 17 individuals with autism, which demonstrated significant improvements in irritability, stereotypy, hyperactivity, and excessive speech in patients in the therapy group. The study also reviewed an earlier version of the 2011 Cochrane review by Sinha et al referenced above. Overall, the authors concluded that there was Grade C evidence related to the use of auditory integration therapy in autism (at least 1 level 2b [individual prospective, nonrandomized cohort study or low-quality RCT] or 3b [systematic review of retrospective case-control studies with homogeneity] studies OR 2 level 4 studies [case series or reports]).

Practice Guidelines and Position Statements

In 1998, the AAP Committee on Children with Disabilities issued a statement on auditory integration training and facilitated communication for autism, which concluded, “Currently available information does not support the claims of proponents that these treatments are efficacious. Their use does not appear warranted at this time, except within research protocols.”

In 2003, the American Speech-Language-Hearing Association (ASHA) Working Group on Auditory Integration Training issued a report on Auditory Integration Training. The review concluded, “Despite approximately one decade of practice in this country, this method has not met scientific standards for efficacy and safety that would justify its inclusion as a mainstream treatment for these disorders.”

Section Summary

The largest body of evidence related to the use of auditory integration therapy is in the treatment of autism. A 2011 Cochrane review and several earlier systematic reviews generally found that studies of auditory integration therapy failed to demonstrate meaningful clinical improvements. No subsequent comparative studies of auditory integration therapy were identified.

Clinical Trials

A search of the online database ClinicalTrials.gov in September 2014 identified no ongoing trials of sensory or auditory integration therapy.

U.S. Preventive Services Task Force Recommendations

Sensory integration therapy and auditory integration therapy are not preventive services.

References

[TOP]

  1. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Sensory Integration Therapy. TEC Assessments 1999; Tab 22.
  2. Uyanik M, Bumin G, Kayihan H. Comparison of different therapy approaches in children with Down syndrome. Pediatr Int 2003; 45(1):68-73.
  3. Schaaf, RC and Miller LJ. Occupational therapy using a sensory integrative approach for children with developmental disabilities. Ment Retard Dev Disabil Res Rev 2005; 11(2):143-8.
  4. Myers SM, Johnson CP, the Council on Children with Disabilities, American Academy of Pediatrics Clinical Report: Management of Children with Autism Spectrum Disorders. Pediatrics 2007, 120(5):1162-1182. Available at URL address: http://pediatrics.aappublications.org/content/early/2007/10/29/peds.2007-2362.full.pdf+html. Last accessed October 29, 2014.
  5. May-Benson TA, Koomar JA. Systematic review of the research evidence examining the effectiveness of interventions using a sensory integrative approach for children. Am J Occup Ther 2010; 64(3); 403-14.
  6. Pfeiffer BA, Koenig K, Kinnealey M et al. Effectiveness of sensory integration interventions in children with autism spectrum disorders: a pilot study. Am J Occup Ther 2011; 65(1):76-85.
  7. Addison LR, Piazza CC et al. A comparison of sensory integrative and behavioral therapies as treatment for pediatric feeding disorders. Jrnl of Applied Beh Analysis 2012, 45(3) 455-471.
  8. Zimmer M, Desch L. Sensory integration therapies for children with developmental and behavioral disorders. Pediatrics 2012; 129(6):1186-9. Available at URL address: http://pediatrics.aappublications.org/content/early/2012/05/23/peds.2012-0876.full.pdf+html. Last accessed October 29, 2014.
  9. Roley SS, Bissll J, Clark GF. Providing occupational therapy using sensory integration theory and methods in school-based practice. Am J Occup Ther 2009; 63(6):823-42.
  10. Watling R, Koenig KP, Davies PL et al. Occupational therapy practice guidelines for children and adolescents with challenges in sensory processing and sensory integration. Bethesda, MD: American Occupational Therapy Association Press; 2011. Available at URL address: http://www.guidelines.gov/content.aspx?id=34041. Last accessed October 29, 2014.
  11. Reviewed by practicing pediatrician, January 2007, April 2008, January 2009, January 2010, and January 2011, April 2013.
  12. Reviewed by two practicing pediatricians, April 2014.
  13. Reviewed by a practicing pediatric psychiatrist, April 2014.
  14. BlueCross BlueShield Association (BCBSA). Sensory Integration Therapy. Medical Policy Reference Manual: Policy No. 8.03.13, 2014
  15. American Academy of Pediatrics Committee on Children with Disabilities. Auditory Integration Training and Facilitated Communication for Autism. Pediatrics. August 1, 1998 1998;102(2):431-433
  16. American Speech-Language-Hearing Association. Auditory integration training [Technical Report]. 2004; http://www.asha.org/policy/TR2004-00260.htm#sec1.1.5. Last accessed October 14, 2014.
  17. Rossignol DA. Novel and emerging treatments for autism spectrum disorders: a systematic review. Ann Clin Psychiatry. Oct-Dec 2009;21(4):213-236.
  18. Parr J. Autism. Clin Evid (Online). 2010 Jan 7;2010.
  19. Sinha Y, Silove N, Hayen A, et al. Auditory integration training and other sound therapies for autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2011(12):CD003681
  20. Schaaf RC, Benevides T, Mailloux Z, et al. An intervention for sensory difficulties in children with autism: a randomized trial. J Autism Dev Disord. Jul 2014;44(7):1493-1506.

Coding

[TOP]

Codes

Number

Description

CPT

97533

Sensory integrative technique to enhance sensory processing and promote adaptive responses to environmental demand, direct (one-on-one) patient contact by the provider, each 15 minutes

Type of Service

Occupational Therapy

 

Place of Service

Outpatient

 

Appendix

[TOP]

N/A

History

[TOP]

Date

Reason

06/27/00

Add to Therapy Section - New Policy

12/21/00

Replace Policy - New CPT codes.

05/13/03

Replace Policy - Policy updated; policy statement unchanged.

10/12/04

Replace Policy - Policy updated with literature review; no change in policy statement.

02/14/06

REPLACE POLICY WITH PR - New Policy replacing BC.8.03.13. Policy statement revised to allow sensory integration therapy as medically necessary when certain medical conditions are present and investigational when treating for psychiatric disorders. Rationale and References updated.

06/23/06

Update Scope and Disclaimer - No other changes.

02/13/07

Replace Policy - Policy updated with literature review. Policy statement clarified regarding the medical necessity of sensory integration for autism only when specifically targeting feeding intolerance, tactile intolerance or balance and proprioception problems.

04/10/07

Cross Reference Update - No other changes.

5/13/08

Replace Policy - Policy updated with literature search. Policy statement clarified from other pervasive mental disorders changed to other pervasive developmental disorders. References updated.

10/14/08

Replace Policy - Policy updated with literature review. Policy statement revised to remove list of investigational disorders and restate: Sensory integration is considered investigational for all other uses.

02/10/09

Replace Policy - Policy updated with literature search. Policy statement clarified to indicate that the policy refers to children (Sensory integration interventions in children may be considered medically necessary under certain conditions.) Reference added.

02/09/10

Replace Policy - Policy updated with literature search. No change to policy statement.

03/08/11

Replace Policy - Policy updated with literature review; reference added. No change in policy statement.

04/25/12

Replace policy. Policy updated with literature search; reference added. No change to policy statement.

05/28/13

Replace policy. Rationale section reformatted, updated based on a literature review through March 2013. References 6-8 added; others renumbered or removed. Practice Guidelines and Position Statements section added. Diagnosis codes added. Policy statement rewritten for clarity, intent is unchanged.

05/05/14

Annual Review. Policy statements clarified with addition of “that is pathological for a child's age and developmental stage”. Definition of Terms added to the Policy Guidelines section. A literature search through March 2014 did not prompt any changes to the rationale section. No new references added. Policy statements revised as noted, intent is unchanged.

05/20/14

Update Related Policies. Remove 8.03.504 as it was archived.

11/10/14

Interim review. Policy updated with literature review through September 23, 2014. Policy statement expanded to include investigational statement for auditory integration therapy; title changed to reflect inclusion of auditory integration therapy. iLS Total Focus info added as non-covered service. Guidelines, Rationale and References revised. Diagnosis codes removed to align with mapping project.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
©2014 Premera All Rights Reserved.