mp-333
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Sensory Integration Therapy and Auditory Integration Therapy

Policy Number: MP-333

Latest Review Date: March 2020

Category:  Therapy                                                                

Policy Grade: B

POLICY:

Sensory Integration Therapy (SIT) and auditory integration therapy are considered not medically necessary and investigational.

For constraint induced therapy, please refer to MP #188- Constraint Induced Movement or Language Therapy.

For cognitive/neurobehavioral/neurorestorative rehabilitation, please refer to MP #600- Cognitive/Neurobehavioral/Neurorestorative Rehabilitation.

DESCRIPTION OF PROCEDURE OR SERVICE:

Sensory integration (SI) therapy has been proposed as a treatment of developmental disorders in patients with established dysfunction of sensory processing, particularly autism spectrum disorders. SI therapy may be offered by occupational and physical therapists who are certified in SI therapy. Auditory integration (AI) therapy uses gradual exposure to certain types of sounds to improve communication in a variety of developmental disorders, particularly autism.

 

The goal of sensory integration (SIT) 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.

Auditory integration (AIT) therapy (also known as auditory integration training, auditory enhancement training, and audio-psycho-phonology) involves having individuals listen to music modified to remove frequencies to which they are hypersensitive, with the goal of gradually increasing exposure to sensitive frequencies. Although several methods have been developed, the most widely-described is the Berard method, which involves two half-hour sessions per day separated by at least three hours, over ten 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.

KEY POINTS:

The most recent literature update was performed through January 13, 2020.

Summary of Evidence

For individuals who have developmental disorders who receive SIT, the evidence includes randomized controlled trials, systematic reviews of these trials, and case series. Relevant outcomes are functional outcomes and quality of life. Due to the individual approach to SI therapy and the large variation in patient’s disorders, large multicenter randomized controlled trials (RCTs) are needed to evaluate the efficacy of this intervention. The most direct evidence related to outcomes from SI therapy comes from several randomized trials. Although some of the studies demonstrated some improvements on subsets of the outcomes measured, the studies are limited by small sizes, heterogeneous patient populations, and variable outcome measures. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have developmental disorders who receive AIT, the evidence includes several randomized controlled trials (RCTs) and systematic reviews of these trials. Relevant outcomes are functional outcomes and quality of life. For AIT therapy, the largest body of literature relates to its use in autism. Several systematic reviews of AI therapy in the treatment of autism found limited evidence to support its use. No comparative studies were identified that evaluate the use of AI therapy for other conditions. The evidence is insufficient to determine the effects of the technology on health outcomes.

PRACTICE GUIDELINES AND POSITION STATEMENTS

Sensory Integration Therapy

American Academy of Pediatrics

A 2012 policy statement by the AAP on SIT 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.

American Occupational Therapy Association

In 2015, the American Occupational Therapy Association (AOTA) guidelines stated: “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 ...to “enhanc[e] a person’s ability to participate in life through engagement in everyday activities….When children demonstrate sensory, motor, or praxis deficits that interfere with their ability to access the general education curriculum, occupational therapy using an SI approach is appropriate.”

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).

U.S. PREVENTIVE SERVICES TASK FORCE RECOMMENDATIONS

Not applicable.

KEY WORDS:

Sensory integration therapy (SIT), auditory integration therapy (AIT), facilitated communication (FC) therapy, Integrated Listening System Therapy, iLs

APPROVED BY GOVERNING BODIES:

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.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts:  FEP does not consider investigational if FDA approved and will be reviewed for medical necessity.

CODING:

CPT Codes:

97533

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

The code above may also be used for auditory integration therapy.

REFERENCES:

  1. 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.

  2. American Speech-Language-Hearing Association. Auditory integration training [Technical Report]. 2004; www.asha.org/policy/TR2004-00260.htm#sec1.1.5.

  3. Baranek GT. Efficacy of sensory and motor interventions for children with autism. J Autism Dev Disord 2002; 32(5):397-422.
  4. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Sensory integration therapy. TEC Assessment. 1999;Volume 14, Tab 22.
  5. Brondino N, Fusar-Poli L, Rocchetti M, et al. Complementary and Alternative Therapies for Autism Spectrum Disorder. Evid Based Complement Alternat Med. 2015; 2015:258589.
  6. 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.
  7. Case-Smith J, Weaver LL, Fristad MA. A systematic review of sensory processing interventions for children with autism spectrum disorders. Autism. Jan 29 2014.
  8. Committee on Children with Disabilities. Auditory integration training and facilitated communication for autism. American Academy of Pediatrics. Committee on Children with Disabilities. Pediatrics. Aug 1998; 102(2 Pt 1):431-433.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. Myers SM, Johnson CP. Management of children with autism spectrum disorders. Pediatrics 2007; 120(5):1162-82.
  14. Occupational Therapy for Children and Youth Using Sensory Integration Theory and Methods in School-Based Practice. Am J Occup Ther. 2015 Nov;69 Suppl 3:6913410040p1-6913410040p20.
  15. Parham LD, Cohn ES, Spitzer S et al. Fidelity in sensory integration intervention research. Am J Occup Ther 2007; 61(2):216-27.
  16. Parr J. Autism. Clin Evid (Online). 2010; 2010.
  17. 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.
  18. 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.
  19. Rossignol DA. Novel and emerging treatments for autism spectrum disorders: a systematic review. Ann Clin Psychiatry. Oct-Dec 2009; 21(4):213-236.
  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.
  21. Schaaf RC, Burke JP, Cohn E, et al. State of measurement in occupational therapy using sensory integration. Am J Occup Ther. Sep-Oct 2014;68(5):e149-153.
  22. 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.
  23. Uyanik M, Bumin G, Kayihan H. Comparison of different therapy approaches in children with Down syndrome. Pediatr Int 2003; 45(1):68-73.
  24. Watling R, Hauer S. Effectiveness of Ayres Sensory Integration(R) and Sensory-Based Interventions for People with Autism Spectrum Disorder: A Systematic Review. Am J Occup Ther. Sep-Oct 2015; 69(5):6905180030p6905180031-6905180012.
  25. 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: www.guidelines.gov/content.aspx?id=34041. Last accessed December 2013.
  26. Woo, C.C., & Leon, M. (2013). Environmental enrichment as an effective treatment for autism: A randomized controlled trial. Behavioral Neuroscience, 487-497.
  27. Zimmer M, Desch L. Sensory integration therapies for children with developmental and behavioral disorders. Pediatrics 2012; 129(6):1186-9.

POLICY HISTORY:

Medical Policy Group, October 2008 (3)

Medical Policy Administration Committee, November 2008

Available for comment November 20, 2008-January 5, 2009

Medical Policy Group, October 2010 (1): Key points update, no policy statement change

Medical Policy Group, October 2011 (1): Update to Key Points and References related to SIT; no change to policy statement.

Medical Policy Panel, October 2013.

Medical Policy Group, December 2013 (2): Deleted “Auditory Integration Therapy and Facilitated Communication” from title, description, and policy statement.   Key Points and References updated to reflect findings from literature search through September 2013

Medical Policy Panel, November 2014

Medical Policy Group, November 2014 (4): Added “and Auditory Integration Therapy” back to title and policy statement.  Updates to Description, Key Points, and References

Medical Policy Group, October 2015 (4): Added “refer to” statements under policy section for MP# 188 and 600.

Medical Policy Group, November 2015 (4): Added integrated listening therapy to Key Words

Medical Policy Panel, March 2016

Medical Policy Group, March 2016 (6):  Updates to Description, Key Points and References; no change to policy statement.

Medical Policy Panel, March 2017

Medical Policy Group, March 2017 (6): Updates to Key Points and References. No change to policy statement.

Medical Policy Panel, March 2018

Medical Policy Group, March 2018 (6): Updates to Description and Key Points. No change to policy statement.

Medical Policy Panel, March 2019

Medical Policy Group, March 2019 (6):  Updates to Key Points.  No change to policy statement.

Medical Policy Panel, March 2020

Medical Policy Group, March 2020 (6): Updates to Key Points, Practice Guidelines and Position Statements, and References. No change to Policy Statement.

 

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

 

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

 

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.