MEDICAL POLICY

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

Sensory Integration Therapy

Number 8.03.500

Effective Date May 28, 2013

Revision Date(s) 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

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

  • Balance and proprioception difficulties
  • Feeding intolerance
  • Tactile intolerance

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

Related Policies

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8.03.503

Occupational Therapy

8.03.504

Cognitive Rehabilitation

Policy Guidelines

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Sensory integration therapy (SIT) is delivered 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 completed within 10 – 20 treatments.

There is a CPT code assigned for SIT:

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.

Description

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Sensory integration disorder, also known as sensory integration dysfunction is the inability of the brain to correctly organize and process information captured by the senses. Usually the sensory information processed by the brain generates an appropriate behavioral and/or motor response. In the case of children with sensory integration disorder the brain processes incoming sensory information incorrectly resulting in an inappropriate or dysfunctional behavioral and/or motor response.

Sensory integration therapy is a technique designed to guide interventions for children who have significant difficulty processing sensory information. The approach has been investigated as a treatment of developmental disabilities, autism, developmental delay, mental retardation, and learning disabilities. It is a treatment modality of unusual complexity, consisting of both the sensory stimulation selected to match a child’s sensory needs and the child’s adaptive responses to the sensory stimulation received. The therapy usually involves full body movements that provide vestibular, proprioceptive, and tactile stimulation. The goal of therapy is to improve the way the brain processes, organizes, and adapts to sensory information, as opposed to teaching specific higher order skills.

Sensory integration therapy’s focus is on adaptive behavior and functional skills and is most frequently utilized by occupational therapists as one component of a comprehensive rehabilitation program.

Formal sensory integration therapy treatment sessions are usually delivered in a one-on-one setting by occupational therapists (OT) and sometimes physical therapists (PT) certified in sensory integration therapy with special training in the theory, techniques, and assessment tools unique to sensory integration theory.

Two organizations currently offer certification for sensory integration therapy:

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

Sensory integration therapy may be considered a component of cognitive rehabilitation therapy. Cognitive rehabilitation is addressed in a separate medical policy. (See Related Policies)

Scope

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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.

Benefit Application

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

Rationale

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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 for the period April 2012 through March 2013. Following is a summary of the key literature.

A 2000 TEC Assessment (1) 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:

  • The TEC Assessment identified only one study that focused on the use of sensory integration therapy in patients with autism. The study included only 5 children and there was no control group.
  • The 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.
  • The TEC Assessment identified 11 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 3 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. (2) 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. (3)

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. (4)

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. (5)

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). (6) 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”. (7)

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 (4). 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 (8)

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. (9) In 2011, the AOTA published evidence-based occupational therapy practice guidelines for children and adolescents with challenges in sensory processing and sensory integration. (10)

References

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  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 April 17, 2013.
  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.
  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 April 17, 2013.
  11. Reviewed by practicing pediatrician, January 2007, April 2008, January 2009, January 2010, and January 2011, April 2013.
  12. BlueCross BlueShield Association. Sensory Integration Therapy. Medical Policy Reference Manual: Policy No. 8.03.13, 2013.

Coding

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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

ICD-9 Procedure

   

ICD-9 Diagnosis

299.00-299.01

Infantile autism code range

 

315.00-315.9

Specific delays in development code range

 

319

Unspecified mental retardation

 

781.99

Other symptoms involving nervous and musculoskeletal systems

 

783.40

Lack of normal physiological development, unspecified

 

783.42

Delayed milestones

HCPCS

   

ICD-10-CM
(effective 10/01/14)

F84.0-F84.9

Pervasive developmental disorders code range (includes infantile autism, etc.)

ICD-10-PCS
(effective 10/01/14)

   

Type of Service

Occupational Therapy

 

Place of Service

Outpatient

 

Appendix

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N/A

History

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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.


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).
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