BlueCross and BlueShield of Montana Medical Policy/Codes
Hippotherapy
Chapter: Therapies
Current Effective Date: May 09, 2013
Original Effective Date: March 05, 2010
Publish Date: May 09, 2013
Revised Dates: August 1, 2012; April 8, 2013
Description

Hippotherapy, also referred to as equine movement therapy, describes physical therapy using a horse.  This strategy utilizes equine movement (hippotherapy) that is utilized as part of an integrated treatment program to achieve functional outcomes.  The primary goals are normalizing muscle tone, equilibrium reactions, head, neck and trunk control, coordination and spatial orientation.  The multidimensional swinging rhythm of the horse’s walk is thought to transfer to the patient’s pelvis in a manner that has been claimed to duplicate the normal human gait.  The hypothesis for the use of hippotherapy is that the horse influences the rider rather than the rider controlling the horse.  The movement of the horse is the treatment tool to achieve the goals of strength, balance and normalizing muscle tone.

Patients with spastic cerebral palsy (CP) frequently have impaired walking ability due to hyperactive tendon reflexes, muscle hypertonias, and increased resistance to increasing velocity of muscle stretch.  These abnormalities result in a lack of selective muscle control and poor equilibrium responses.  Hippotherapy has been proposed as a technique to decrease the energy requirements and improve walking in patients with CP.  It is hoped that the multi-sensory environment may also be beneficial to children with profound social and communication deficits, such as autism spectrum disorder and also developmental disorders such as Down syndrome.

Simulated hippotherapy using a new device has been studied in European centers.  Therapeutic interventions using such a device would be conducted in the physical/occupational therapy setting and are outside the scope of this policy.

Policy

Investigational

Blue Cross and Blue Shield of Montana (BCBSMT) considers hippotherapy experimental, investigational and unproven.

Federal Mandate

Federal mandate prohibits denial of any drug, device or biological product fully approved by the FDA as investigational for the Federal Employee Program (FEP). In these instances coverage of these FDA-approved technologies are reviewed on the basis of medical necessity alone.

Rationale for Benefit Administration
 
This medical policy was developed through consideration of peer reviewed medical literature, FDA approval status, accepted standards of medical practice in Montana, Technology Evaluation Center evaluations, and the concept of medical necessity. BCBSMT reserves the right to make exceptions to policy that benefit the member when advances in technology or new medical information become available.

The purpose of medical policy is to guide coverage decisions and is not intended to influence treatment decisions. Providers are expected to make treatment decisions based on their medical judgment. Blue Cross and Blue Shield of Montana recognizes the rapidly changing nature of technological development and welcomes provider feedback on all medical policies.

When using this policy to determine whether a service, supply, drug or device will be covered, please note that member contract language will take precedence over medical policy when there is a conflict.

Rationale

At the time this policy was created, the majority of the literature regarding hippotherapy consisted of small case series, most of which were published in German literature.  One small randomized study of 19 patients was identified that reported no significant effects in the majority of outcome measures.

Literature searches of the MEDLINE® database have been performed periodically since 2000; the most recent search was conducted in May 2011.  Several systematic reviews on hippotherapy have been published recently.  One of the systematic reviews concluded that there was evidence from one or more randomized controlled trials (RCTs) of fair quality studies that a short intervention of hippotherapy is effective for treating muscle symmetry in the trunk and hip when compared with static sitting.  The review found three quasi-experimental studies with positive results for gross motor function and functional performance in the home and community. Another systematic review reported that five of six moderate quality studies (small sample sizes and lack of a control non-riding group) found improved gross motor function in children with cerebral palsy (CP).  A systematic review from 2009 concluded that strong evidence indicates that children and adolescents with developmental disabilities derive health benefits from participation in group exercise programs, treadmill training, or therapeutic riding/hippotherapy; however, three of the studies included in the review showed that therapeutic horseback riding is no more effective than other therapies for improving muscle tone in children with CP and that it is no more effective than no intervention for posture, self-esteem, and global behavior.

Hippotherapy for patients with multiple sclerosis (MS) was addressed in a 2010 systematic review of three studies.  A case control study with nine subjects by Silkwood-Sherer and Warmbier included in the review is discussed below.  Each of the other studies, both case series, had 11 subjects.  The authors concluded that the studies provided emerging, but limited, evidence that hippotherapy improves balance in persons with MS acknowledging limitations of small sample size, lack of randomization, especially given the variable nature of MS, and lack of controls in two studies.

Examples of the primary literature include a study by Sterba and colleagues, who reported on the outcomes of horseback riding in 17 subjects with CP.  Gross motor function measurements were assessed before and after a once weekly horseback riding program for 18 weeks.  Gross motor function total scores improved by 7.6% after 18 weeks, returning to baseline six weeks after the program ended.  In another study, Benda and colleagues used surface electromyography to assess outcomes in 15 children with CP who were randomly assigned to either horseback riding or to sitting stationary astride a barrel.  The authors reported that the hippotherapy group showed greater symmetry of muscle activity.  The clinical significance of this outcome is uncertain. Another small study of 12 patients with spastic spinal cord injury found hippotherapy to result in short-term improvements in spasticity and well-being.  A study of nine patients with MS found that 14 weekly sessions of hippotherapy improved balance in comparison with a control group of six patients. 

In 2009, a randomized trial was published that included 72 children (85% of the 99 families enrolled) aged 4–12 years with CP who completed a 10-week session of hippotherapy with pre- and post-treatment assessments.  Randomization to hippotherapy or a waiting-list control with usual therapy was stratified by age and level of gross motor function.  The physiotherapist assessor was blinded to the randomization, and the participants were asked not to mention if they had completed the intervention at the time of the assessment.  No differences between the hippotherapy and control groups were found for functional status (therapist-assessed) or child-reported quality of life.  Minor differences were found in parent-reported quality of life and child health scores in the domain of family cohesion.  Overall, therapeutic horseback riding was not found to have a clinically significant impact on children with CP.

McGibbon et al. investigated the impact of hippotherapy on symmetry of adductor muscle during walking.  In Phase I of the trial, they randomly assigned 47 children aged 4-16 years with spastic CP to receive a single 10-minute session of either hippotherapy or barrel sitting.  Adductor muscle symmetry was measured before and after the session.  The hippotherapy group demonstrated a statistically significant difference in adductor symmetry after this single intervention.  Six of the children went on to participate in Phase II, a 36-week study (12 weeks without hippotherapy [baseline], 12 weeks of weekly intervention, and 12 weeks without intervention).  Four of six subjects showed improved symmetry during walking after 12 weeks of intervention, and improvement was maintained after 12 more weeks.  All six children improved on the Gross Motor Function Measure-66, and one child began walking without a walker after four weeks of hippotherapy.  Five children improved in at least one area of Self-Perception Profiles.  The authors note a number of limitations of the study including small sample size in Phase II, the diversity of subjects in the distribution of their spasticity, and the inclusion of children with mixed characteristics.

A series of 11 children aged 5-13 years with CP demonstrated improved trunk/head stability and upper extremity reaching/targeting after 12 weekly 45-minute sessions of hippotherapy.  Results were compared with those of eight children without disability who did not receive an intervention.  The impact of hippotherapy versus other forms of therapy directed to trunk/head stability and upper extremity reaching cannot be determined from this study.

Summary

Literature on hippotherapy is limited, consisting primarily of small uncontrolled case series.  In the largest randomized trial conducted to date (72 children), hippotherapy was found to have no clinically significant impact on children with cerebral palsy.  The literature at this time does not support the conclusion that hippotherapy is as effective as the existing alternatives and does not demonstrate improvement in net health outcome.  Therefore, the treatment is considered investigational.

2011 Update

A search of peer reviewed literature through May 2011 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

ICD-9 Codes

299.0, 299.00, 299.01, 340,343.1, 343.3, 343.9, 344-344.1, 344.8, 344.89, 344.9, 758.0, 767.4, 952.2, 952.3, 952.4, 952.8, 952.9

ICD-10 Codes
G80.0 – G80.9 
Procedural Codes: 97110, 97112, S8940
References
  1. Bertoti, D.B.  Effect of therapeutic horseback riding on posture in children with cerebral palsy. Physical Therapy (1988 October) 68(10):1505-12.
  2. MacKinnon, J.R., Noh, S., et al.  A study of therapeutic effects of horseback riding for children with cerebral palsy.  Phys Occup Ther Pediatr (1995) 15(1):17-34.
  3. McGibbon, N.H., Andrade, C.K., et al.  Effect of an equine-movement therapy program on gait, energy expenditure, and motor function in children with spastic cerebral palsy:  A pilot study. Developmental Medicine and Child Neurology (1998) 40:754-62.
  4. Sterba, J.A., Rogers, B.T., et al.  Horseback riding in children with cerebral palsy: effect on gross motor function.  Developmental Medicine and Child Neurology (2002 May) 44(5):301-8.
  5. Benda, W., McGibbon, N.H., et al.  Improvements in muscle symmetry in children with cerebral palsy after equine-assisted therapy (hippotherapy).  Journal of Alternative Medicine (2003 December) 9(6):817-25.
  6. Hammer, A., Nilsagard, Y., et al.  Evaluation of therapeutic riding (Sweden)/hippotherapy (United States).  A single-subject experimental design study replicated in eleven patients with multiple sclerosis.  Physiotherapy Theory and Practice (2005 January through March) 21(1):51-77.
  7. Snider, L., Korner-Bitensky, N., et al.  Horseback riding as therapy for children with cerebral palsy: is there evidence of its effectiveness?  Phys Occup Ther Pediatr (2007) 27(2):5-23.
  8. Sterba, J.A.  Does horseback riding therapy or therapist-directed hippotherapy rehabilitate children with cerebral palsy?  Dev Med Child Neurol (2007) 49(1):68-73.
  9. Lechner, H.E., Kakebeeke, T.H., et al.  The effect of hippotherapy on spasticity and on mental well-being of persons with spinal cord injury.  Arch Phys Med Rehabil (2007) 88(10):1241-8.
  10. Silkwood-Sherer, D., and H. Warmbier.  Effects of hippotherapy on postural stability, in persons with multiple sclerosis: a pilot study.  J Neurol Phys Ther (2007) 31(2):77-84.
  11. Davis, E., Davies, B., et al.  A randomized controlled trial of the impact of therapeutic horse riding on the quality of life, health, and function of children with cerebral palsy.  Dev Med Child Neurol (2009) 51(2):111-9.
  12. Shurtleff, T.L., Standeven, J.W., et al.  Changes in dynamic trunk/head stability and functional reach after hippotherapy. Arch Phys Med Rehabil (2009) 90(7):1185-95.
  13. Johnson, C.C.  The benefits of physical activity for youth with developmental disabilities: a systematic review. Am J Health Promot (2009) 23(3):157-67.
  14. McGibbon, N.H., Benda, W., et al.  Immediate and long-term effects of hippotherapy on symmetry of adductor muscle activity and functional ability in children with spastic cerebral palsy.  Arch Phys Med Rehabil (2009) 90(60):966-74.
  15. Bronson, C., Brewerton, K., et al.  Does hippotherapy improve balance in persons with multiple sclerosis: a systematic review.  Eur J Phys Rehabil Med (2010) 46(3):347-53.
  16. Hippotherapy.  Chicago, Illinois:  Blue Cross Blue Shield Association Medical Policy Reference Manual (2011 February) Therapy: 8.03.12.
History
August 2012  Policy updated with literature search through August 2011, reference 7 added, policy statement unchanged
April 2013 Title changed from "Horseback Riding Therapy (Hippotherapy)" to "Hippotherapy".  Policy language and formatting revised.  Policy statement unchanged.  Added codes 97110 and 97112.
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Hippotherapy