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Date Printed: October 20, 2017: 08:41 AM

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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.

01-97000-05

Original Effective Date: 09/15/01

Reviewed: 10/22/09

Revised: 11/01/15

Subject: Sensory Stimulation for Coma Patients

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 stimulation is intended to promote awakening and enhance the rehabilitative potential of coma patients. Protocols may involve stimulation of any or all of the following senses: visual, auditory, olfactory, gustatory, cutaneous, and kinesthetic. Various stimuli may be used for each sense. Protocols may differ with respect to who performs the stimulation and where. Professionals include nurses, occupational therapists, physical therapists, and speech-language therapists. In some cases, family members may be trained in the techniques and are given primary responsibility for providing the therapy. Treatment may be delivered in the hospital, the patient’s home, or a nursing home.

POSITION STATEMENT:

Sensory stimulation for coma patients is considered experimental and investigational because there is inadequate scientific data to permit conclusions regarding the effectiveness of coma stimulation. The evidence on the effectiveness of sensory stimulation for coma patients does not permit conclusions of this technology on health outcomes.

BILLING/CODING INFORMATION:

HCPCS Coding:

S9056

Coma stimulation per diem (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:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

No guideline specific definitions that apply.

RELATED GUIDELINES:

None applicable.

OTHER:

Other names used to report sensory stimulation for coma patients:

Coma stimulation

REFERENCES:

  1. Blue Cross and Blue Shield Association Medical Policy Reference Manual 2.01.24 Sensory Stimulation for Coma Patients, (04/17/07).
  2. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Sensory Stimulation For Coma Patients, TEC Assessments 1989, p 269-77.
  3. ECRI Health Technology Assessment Information Services. Custom Hotline Response. Sensory Stimulation for Reducing Time to Recovery from Coma or Vegetative State. Updated 04/12/07.
  4. Lombardi F, Taricco M, De Tanti A, Telaro E, Liberati A. Sensory stimulation for brain injured individuals in coma or vegetative state (Cochrane Review). The Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD001427. DOI: 10.1002/14651858.CD001427.
  5. Pape TL, Heinemann AW, Kelly JP, Hurder AG, Lundgren S. A measure of neurobehavioral functioning after coma. Part I: Theory, reliability, and validity of Disorders of Consciousness Scale. J Rehabil Res Dev. 2005 Jan-Feb; 42(1): 1-18.
  6. Pape TL, Senno RG, Guernon A, Kelly JP. A measure of neurobehavioral functioning after coma. Part II: Clinical and scientific implementation. J Rehabil Res Dev. 2005 Jan-Feb; 42(1): 19-28.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 10/22/09.

GUIDELINE UPDATE INFORMATION:

09/15/01

New Medical Coverage Guideline.

12/15/02

Annual review for investigational; no change.

11/15/03

Reviewed; no changes (investigational).

11/15/04

Review and revision; consisting of updated references and maintaining investigational status.

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.

11/15/09

Scheduled review; no change in position statement.

05/11/14

Revision: Program Exceptions section updated.

11/01/15

Revision: ICD-9 Codes deleted.

Date Printed: October 20, 2017: 08:41 AM