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Medical Policy: 08.03.04
Original Effective Date: August 2000
Reviewed: September 2011
Revised:
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Sensory integration therapy is a technique used in the treatment of autism, mental retardation, and learning disability. It is an unusually complex modality consisting of both the sensory stimulation selected to match a child's sensory needs and the child's adaptive responses to the sensory stimulation. The therapy usually involves full body movements that provide tactile, proprioceptive, and tactile stimulation.
The goal of therapy is to improve the way the brain processes and organizes sensations, as opposed to teaching specific higher order skills. Treatment sessions are usually delivered in a one-on-one setting by occupational therapists, physical therapists or speech therapists with special training in the theory, techniques and assessment tools unique to sensory integration therapy. The sessions may be intensive, and the course of treatment often lasts for more than one year.
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Prior Approval:
Not applicable
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Policy:
Sensory integration therapy is considered investigational.
Overall the evidence is insufficient to evaluate the effect of this treatment on health outcomes. Due to the individual nature of sensory integration therapy and the large variation in individual therapists and patients, large multi-center randomized controlled trials are needed to evaluate the efficacy of this intervention.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 97533 Sensory Integration Therapy.
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Selected References:
- AOTA (American Occupational Therapy Association) (1999). Statement: Sensory integration evaluation and intervention in school-based occupational therapy. (personal communication, Marian Scheinholtz, Practice Associate, AOTA, December 1, 1999).
- Case-Smith J, Bryan T. The effects of occupational therapy with sensory integration emphasis on preschool-age children with autism. American Journal of Occupational Therapy, 1999, 53(5): 489-497.
- Gresham FM, MacMillan DL. Early Intervention Project: can its claims be substantiated and its effects replicated. Journal of Autism Development Disorder,1998, 28(1):5-13.
- Vargas S, Camilli G. A meta-analysis of research on sensory integration treatment. American Journal of Occupational Therapy, 1999, 53(2): 189-98.
- Dawson G, Watling R. Interventions to facilitate auditory, visual, and motor integration in autism: a review of the evidence. J Autism Dev Disord. 2000 Oct;30(5):423-5.
- 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):228-238.
- Schaaf R, Blanche EI. Comparison of behavioral intervention and sensory-integration therapy in the treatment of challenging behavior. J Autism Dev Disord. 2011 Jun 11. [Epub ahead of print].
- Parham LD, Roley SS, May-Benson TA et al. Development of a fidelity measure for research on the effectiveness of the Ayres Sensory Integration intervention. Am J Occup Ther. 2011 Mar-Apr; 65(2):133-42.
- 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 Jan-Feb; 65(1):76-85.
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Policy History:
Date Reason Action
September 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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