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Date Printed: June 28, 2017: 11:52 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-97000-03

Original Effective Date: 11/15/00

Reviewed: 10/27/11

Revised: 11/01/15

Subject: Sensory Integration Therapy

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates  

DESCRIPTION:

Sensory integration 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 (SI) 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 practice, and mentorship in the theory, techniques, and assessment tools unique to SI theory. Two organizations currently offer certification for SI 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), 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.

Sensory integration therapy may be considered a component of cognitive rehabilitation therapy. Cognitive rehabilitation is discussed in MCG#01-97000-04.

POSITION STATEMENT:

Sensory integration therapy is considered experimental or investigational for ALL applications because there is insufficient scientific evidence to support the effectiveness of sensory integration therapy.

BILLING/CODING INFORMATION:

CPT Coding:

97533

Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one on one) patient contact, each 15 minutes (investigational).

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Therapy and Rehabilitation Services (L29289) located at fcso.com.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Cognitive Rehabilitation, 01-97000-04

OTHER:

None applicable.

REFERENCES:

  1. AHRQ Agency for Healthcare Research and Quality. Guideline Summary: Treatment and management of ASD. New Zealand autism spectrum disorder guideline. NGC-007354. Wellington (New Zealand): Ministry of Health; 2008. p. 133-62.
  2. AHRQ Agency for Healthcare Research and Quality. Guideline Summary: Occupational therapy practice guidelines for children and adolescents with autism. Bethesda (MD): American Occupational Therapy Association (AOTA); 2009. 132 p.
  3. Blue Cross and Blue Shield Association Medical Policy Reference Manual – 8.03.13 Sensory Integration Therapy 12/13/07October 2010.
  4. Blue Cross Blue Shield Association Technology Evaluation Center (TEC). – Sensory Integration Therapy – TEC Assessments 1999, Tab 22.
  5. ClinicalTrials.gov. Occupational Therapy to Treat Children Who Over or Under React to Their Environment. NCT00006507. Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). Last Updated on January 16, 2007.
  6. Committee on Children with Disabilities. Technical report: the pediatrician's role in the diagnosis and management of autistic spectrum disorder in children. Pediatrics. 2001 May; 107(5): E85.
  7. ECRI Health Technology Assessment Information Services Executive Briefing “Comprehensive Programs for the Treatment of Children with Autism” (No 89, May 2000).
  8. ECRI. Custom Hotline Response. Sensory Integration Therapy for Sensory Integration Dysfunction. Plymouth Meeting, PA: ECRI. 05/21/08.
  9. Florida Medicare Part B Local Coverage Determination THERSVCS Therapy and Rehabilitation Services 07/01/08.
  10. Florida Medicare Part B Local Coverage Determination. LCD for Therapy and Rehabilitation Services (L29289) 02/02/09. Last updated 01/01/11.
  11. Hayes, Inc. Hayes Medical Technology Directory. Sensory Integration Therapy for Children with Learning Disabilities or Developmental Delays. Lansdale, PA: Hayes, Inc.; December 2004. Update performed 01/20/08.
  12. Hender K. Effectiveness of sensory integration therapy for attention deficit hyperactivity disorder (ADHD). Evidence Centre Critical Appraisal. Series 2001: Intervention. Clayton, Victoria, Australia: Centre for Clinical Effectiveness, Monash Medical Centre; March 21, 2001.
  13. Michaud LJ; American Academy of Pediatrics Committee on Children With Disabilities. Prescribing therapy services for children with motor disabilities. Pediatrics. 2004 Jun; 113(6): 1836-8. Reaffirmed on 07/01/11. (Accessed 09/27/11).
  14. Scott M. Myers,Chris Plauché Johnson the Council on Children With Disabilities. Management of Children with Autism Spectrum Disorders. Pediatrics 2007 120: 1162-1182.
  15. Williames LD, Erdie-Lalena CR. Complementary, Holistic, and Integrative Medicine: Sensory Integration. Pediatrics in Review Vol. 30 No. 12 December 1, 2009 pp. e91 -e93.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 10/27/11.

GUIDELINE UPDATE INFORMATION:

11/15/00

New Medical Coverage Guideline.

12/06/01

Annual review for Investigational – no changes.

12/15/02

Annual review for Investigational – no changes.

11/15/03

Annual review for Investigational – no changes.

11/15/04

Review and revision; consisting of updated references.

11/15/05

Review and revision; consisting of updated references.

11/15/06

Review and revision consisting of updated references and maintaining investigational statement.

07/15/07

Review and revision consisting of updated references and reformatted guideline.

11/15/08

Scheduled review; no change in position statement, and update references.

11/15/09

Scheduled review; no change in position statement, and update references.

11/15/11

Scheduled review; no change in position statement. Updated description section and references.

01/01/13

Annual CPT coding update. Revised code descriptor for 97533.

05/11/14

Revision: Program Exceptions section updated.

11/01/15

Revision: ICD-9 Codes deleted.

Date Printed: June 28, 2017: 11:52 PM