BlueCross and BlueShield of Montana Medical Policy/Codes
Sensory Integration Therapy
Chapter: Therapies
Current Effective Date: August 27, 2013
Original Effective Date: March 16, 2011
Publish Date: August 27, 2013
Revised Dates: This policy is no longer scheduled for routine literature review and update. December 10, 2012; July 25, 2013
Description

Sensory integration (SI) therapy (SIT) has been proposed as a treatment of developmental disorders in patients with established dysfunction of sensory processing, e.g., children with autism, attention deficit hyperactivity disorder (ADHD), brain injuries, fetal alcohol syndrome, and eurotransmitter disease. Sensory integration therapy may be offered by occupational and physical therapists who are certified in sensory integration therapy.

The goal of SIT 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. A related method, auditory integration therapy, involves 10 hours of listening to electronically modified music over the course of 10 days.

Treatment sessions are usually delivered in a one-on-one setting by occupational therapists with special training from university curricula, clinical practice, and mentorship in the theory, techniques, and assessment tools unique to SI theory. Two organizations currently offer certification for SIT; Sensory Integration International (SII), a non-profit branch of the Ayres Clinic in Torrence, Calif, and Western Psychological Services, a private organization that has a collaborative arrangement with University of Southern California (USC), Los Angeles, to offer sensory integration training through USC’s Department of Occupational Science and Therapy. The sessions, are often provided as part of a comprehensive occupational therapy or cognitive rehabilitation therapy and may last for more than 1 year.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Investigational

Blue Cross and Blue Shield of Montana (BCBSMT) considers sensory integration therapy (SIT) experimental, investigational and unproven.

Rationale

This policy was originally created in 2011 based on a 1999 Technology Evaluation Center (TEC) Assessment, and has been updated with searches of the MEDLINE database through January 2013. This section of the current policy has been substantially revised. Following is a summary of the key literature to date.

The 1999 TEC Assessment compared the outcomes of sensory integration therapy (SIT) with that of standard occupational/physical therapy among children with autism, mental retardation, or learning disabilities. (1) The literature at that time consisted of 1 study that focused on the use of SI therapy in patients with autism and 3 studies that focused on patients with mental retardation; these 3 studies were inconsistent in their results regarding the superiority of SI therapy. Eleven studies were identified that in total included more than 600 learning disabled children. Studies that used random assignment and blinded assessors suggested that SI 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 SI therapy did not seem to support its effectiveness. Periodic literature searches using the MEDLINE database have been performed regularly since the 1999 TEC Assessment. These updates include small case series. Systematic reviews and comparative studies are described here.

Systematic Reviews

Case-Smith and Arbesman reviewed the evidence for SI therapy as part of a systematic review of interventions for autism used in occupational therapy in 2008. (2) The authors identified one level-1 study, which was a systematic review from 2002 that had found only lower quality evidence (levels III and IV, with small sample size and lack of control groups), suggesting that SI intervention was associated with positive changes in social interaction, purposeful play, and decreased sensitivity. (3) It was concluded, “Although each of these studies had positive findings, when combined, the evidence remains weak and requires further study.”

May-Benson and Koomar published a systematic review of SI therapy in 2010. (4) The review identified 27 research studies (13 level-I 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 SI 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.

A 2011 Cochrane review evaluated auditory integration training along with other sound therapies for autism spectrum disorders. (5) Included were 6 randomized controlled trials of auditory integration therapy and one of Tomatis therapy, involving 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.

Controlled Trials

The Sensory Processing Disorders Scientific Workgroup has discussed the methodologic challenges of conducting intervention effectiveness studies of dynamic interactional processes, the lack of scientific evidence to support current practice, and methods for improving the quality of research in this area. (6, 7) In 2007, members of the workgroup also reported results from a single institution randomized pilot study for a proposed multicenter trial. (8) Thirty families (of approximately 140 who met the inclusion/exclusion criteria) agreed to participate over a 3-year period. The children had a clinical diagnosis of sensory modulation disorder following a comprehensive evaluation with standardized and clinical testing (including responses to sensory stimuli, attempts by the child to self-regulate, behavioral disorganization, and somatic responses to the testing situations). The 24 children who began treatment were randomly assigned to 1 of 3 groups consisting of occupational therapy with SI (2 times per week for 10 weeks, n=7), equivalent activity control sessions (n=10), or a waiting-list control group (n=7). Functional improvements were assessed by 5 validated/standardized parental rating scales. Significant improvements relative to both control groups were obtained for Goal Attainment Scaling (37 vs. 14 vs. 7, consecutively). A number of the other outcome measures (Leitner International Performance Scale, Short Sensory Profile, Internalizing on the Child Behavior Checklist) showed trends for improvement in this small study. Additional study with a larger number of subjects is needed.

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). (9) Fidelity to SI interventions was verified with a fidelity measure developed for research by Parham et al. (7) 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 a 2003 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 SI therapy group and in the neurodevelopmental therapy group when compared to the SI therapy alone group. (10) 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.

Practice Guidelines and Position Statements

The American Academy of Pediatrics (AAP) stated in a 2007 guidance “the efficacy of SI [sensory integration] therapy has not been demonstrated objectively.” (12) The guidance document on management of children autism spectrum disorders is available online at: http://pediatrics.aappublications.org. 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. (13)

In 2009, the American Occupational Therapy Association (AOTA) stated that the AOTA recognizes 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. (14) In 2011, the AOTA published evidence-based occupational therapy practice guidelines for children and adolescents with challenges in sensory processing and sensory integration. (15) AOTA gave a level C recommendation for SIT 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 SI for academic and psychoeducational performance (e.g., math, reading, written performance).

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

Experimental, investigational and unproven for all codes.

ICD-10 Codes

Experimental, investigational and unproven for all codes.

Procedural Codes: 97533
References
  1. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Sensory integration therapy. TEC Assessment 1999; Volume 14, Tab 22.
  2. Case-Smith J, Arbesman M. Evidence-based review of interventions for autism used in or of relevance to occupational therapy. Am J Occup Ther 2008; 62(4):416-29.
  3. Baranek GT. Efficacy of sensory and motor interventions for children with autism. J Autism Dev Disord 2002; 32(5):397-422.
  4. 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.
  5. 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.
  6. Mailloux Z, May-Benson TA, Summers CA et al. Goal attainment scaling as a measure of meaningful outcomes for children with sensory integration disorders. Am J Occup Ther 2007; 61(2):254-9.
  7. Parham LD, Cohn ES, Spitzer S et al. Fidelity in sensory integration intervention research. Am J Occup Ther 2007; 61(2):216-27.
  8. Miller LJ, Coll JR, Schoen SA. A randomized controlled pilot study of the effectiveness of occupational therapy for children with sensory modulation disorder. Am J Occup Ther 2007; 61(2):228-38.
  9. 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.
  10. Uyanik M, Bumin G, Kayihan H. Comparison of different therapy approaches in children with Down syndrome. Pediatr Int 2003; 45(1):68-73.
  11. Kratz SV. Sensory integration intervention: historical concepts, treatment strategies and clinical experiences in three patients with succinic semialdehyde dehydrogenase (SSADH) deficiency. J Inherit Metab Dis 2009; 32(3):353-60.
  12. Myers SM, Johnson CP. Management of children with autism spectrum disorders. Pediatrics 2007; 120(5):1162-82.
  13. Zimmer M, Desch L. Sensory integration therapies for children with developmental and behavioral disorders. Pediatrics 2012; 129(6):1186-9.
  14. Roley SS, Bissell 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.
  15. 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. Guideline summary available online at: http://www.guidelines.gov. Last accessed September 2012.
History
December 2012  Policy updated with leterature review through August 2012.  References 5, 8, 13, 15 added and references reordered.  Policy statement unchanged. 
August 2013 Policy formatting and language revised.  Policy statement unchanged.
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Sensory Integration Therapy