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MP 8.03.13 Sensory Integration Therapy

Medical Policy
Section
Therapy
 
Original Policy Date
4/30/00
Last Review Status/Date
Reviewed with literature search/10:2011
Issue
10:2011
Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

Sensory integration (SI) therapy 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 neurotransmitter disease. Sensory integration therapy may be offered by occupational and physical therapists who are certified in sensory integration therapy.

The goal of sensory integration 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.

Treatment sessions are usually delivered in a one-on-one setting by occupational therapists with special training from university curricula, clinical practica, and mentorship 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 Torrence, Calif, and Western 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 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.

Related Policies:

8.03.10 Cognitive Rehabilitation


Policy

Sensory integration therapy is considered investigational.


Policy Guidelines

In 2001, a new CPT code (97533) was introduced that explicitly identifies sensory integrative therapy.

97533: Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes.


Benefit Application

BlueCard/National Account Issues

Depending on the contract, coverage of sensory integration therapy may be considered under the mental health benefit.

Services related to education may be health plan contract exclusions.


Rationale

This policy was originally based on a 1999 TEC Assessment that compared the outcomes of sensory integration (SI) therapy 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, with the most recent conducted for the period of September 2010 through July 2011, have primarily identified 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 that “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.

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. (5,6) In 2007, members of the workgroup also reported results from a single institution randomized pilot study for a proposed multicenter trial. (7) 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). (8) Fidelity to SI interventions was verified with a fidelity measure developed for research by Parham et al. (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 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. (9) 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.

Summary

Overall, the evidence remains insufficient to evaluate the effect of this treatment on health outcomes. As noted by Kratz, “there exists very little research that supports the effectiveness of any intervention for children with chronic or mild disabilities across all disciplines.” (10) Due to the individual nature of SI therapy and the large variation in individual therapists and patients, large multicenter randomized controlled trials are needed to evaluate the efficacy of this intervention. Therefore, the policy statement remains unchanged.

Practice Guidelines and Position Statements

The 2007 Guidance from the American Academy of Pediatrics (AAP) states that “the efficacy of SI [sensory integration] therapy has not been demonstrated objectively.” (11) The guidance document on management of children autism spectrum disorders is available online at http://pediatrics.aappublications.org/cgi/reprint/peds.2007-2362v1.

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. (12)

 

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. 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.
  6. Parham LD, Cohn ES, Spitzer S et al. Fidelity in sensory integration intervention research. Am J Occup Ther 2007; 61(2):216-27.
  7. 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.
  8. 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.
  9. Uyanik M, Bumin G, Kayihan H. Comparison of different therapy approaches in children with Down syndrome. Pediatr Int 2003; 45(1):68-73.
  10. 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.
  11. Myers SM, Johnson CP. Management of children with autism spectrum disorders. Pediatrics 2007; 120(5):1162-82.
  12. 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. 



     

Codes

Number

Description

CPT  97533  Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, 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 
HCPCS     
ICD-10-CM (effective 10/1/13)   Investigational for all diagnoses 
 F84.0-F84.9  Pervasive developmental disorders code range (includes infantile autism, etc.) 
 ICD-10-PCS (effective 10/1/13)  ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for this therapy. 
Type of Service  Physical therapy 
Place of Service  Outpatient 


Index

Sensory Integration Therapy
Therapy, Sensory Integration  


Policy History

Date Action Reason
04/30/00 Add to Therapy/ Rehabilitation section New policy
10/15/00 Replace policy New CPT Codes
12/18/02 Replace policy Policy updated; policy statement unchanged
07/15/04 Replace policy Literature review update on MEDLINE for the period of October 2002 through May 2004; policy statement unchanged
06/27/05 Replace policy Literature review updated for the period of May 2004 through May 2005; no new clinical trials found. Policy statement unchanged
12/14/05 Replace policy – error correction only Corrected date of TEC Assessment to 1999 in rationale and reference sections
07/20/06 Replace policy Literature review updated for the period of 2005 through May 2006; no new clinical trials found. Policy statement unchanged.
12/13/07 Replace Policy Policy updated with literature review; references 3 - 6 added; policy statement unchanged.
10/06/09 Replace policy Policy updated with literature review through August 2009; references 6-8 added; policy statement unchanged
10/08/10 Replace policy Policy updated with literature review through August 2010; reference numbers 8 and 11 added; policy statement unchanged
10/4/2011 Replace policy Policy updated with literature review through July 2011; reference 8 added and references reordered; policy statement unchanged