Medical Policy: 08.03.04
Original Effective Date: August 2000
Reviewed: March 2016
Revised: April 2015
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.
Sensory Integration Therapy (SIT)
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, brain injuries, fetal alcohol syndrome, and neurotransmitter disease. SI therapy may be offered by occupational and physical therapists who are certified in SI therapy.
Sensory integration refers to the process by which the brain organizes and interprets external stimuli such as touch, movement, body awareness, sight, sound and gravity. It has been suggested that certain behavioral and emotional problems result from the malfunctioning of this process.
The goal of SI therapy is to improve the way the brain processes and adapts to sensory information, as opposed to teaching specific skills. The therapy usually involves activities that provide vestibular, proprioceptive, and tactile stimuli, which are selected to match specific sensory processing deficits of the child. This type of therapy requires activities that consist of full body movements employing different kinds of equipment such as textured mitts, brushes, balls, carpets squares, scooter boards, ramps, swings and bounce pads. It is believed that SI therapy does not teach higher level skills, but enhances the sensory processing abilities of the patient to acquire them.
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. The sessions are often provided as part of a comprehensive occupational therapy or cognitive rehabilitation therapy treatment plan and may last for more than one year.
Due to the individual nature of SI therapy and the large variation in individual therapists and patients, large multicenter randomized controlled trials (RCTs) are needed to evaluate the efficacy of this intervention. The most direct evidence related to outcomes of SI therapy comes from several small randomized trials. Although some of the studies demonstrated some improvements on subsets of the outcomes measured, the studies are limited by small sizes, heterogenous patient populations, and variable outcome measures. As a result, the evidence is insufficient to draw conclusions about the effects of and the most appropriate patient populations for SI therapy, and the use of SI therapy is considered investigational.
Auditory Integration (AI) Therapy
AI therapy (also known as AI training, auditory enhancement training, audio-psycho-phonology) is an intervention developed to correct or improve auditory hypersensitivity, distortions, and delays in the signals that interfere with an individual’s ability to process auditory information normally. Inconsistencies and distortions in the way sounds are perceived can make it difficult to interpret auditory stimuli. In addition, the ears must work together in a coordinated fashion. If the hearing in one ear is different than the other, the person may have auditory processing problems. This lack of coordination between the ears contributes to difficulties in following directions, comprehending what is said or read, and putting thoughts into words. Also, some people hear certain frequencies much better than other frequencies. When this occurs, the person perceives sounds in a distorted manner, may be easily distracted, and may have difficulty understanding auditory information. AI therapy has been proposed for individuals with a range of developmental and behavioral disorders, including learning disabilities, attention deficit and hyperactivity disorder, dyslexia, central auditory processing disorder, sensory processing disorder, and autism and pervasive developmental disorder.
Although several methods have been developed, the most widely described is the Berard method. The Berard method involves listening to music through headphones that is specifically modified by the Earductor TM, or the Audiokinetron, the two current devices designed for Berard AIT. These devices modulate the music, and may be used to filter out specific frequencies. The training is provided for 30 minutes, twice a day for a total of 10 hours. Audio tests prior to training and after the first 5 hours of training indicate whether any narrow band filters may be used. The minimum age is 3 years and there is no upper limit.
Other methods of AI include Tomatis method, which involves listening to electronically modified music and speech, and Somonas Sound Therapy, which involves listening to filtered music, voices and nature sounds.
For auditory integration (AI) 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 evaluated the use of AI therapy for other conditions. Therefore, the use of AI therapy is considered investigational.
Practice Guidelines and Position Statements
American Academy of Pediatrics (AAP)
A 2012 policy statement by the AAP on sensory integration therapies for children with developmental and behavioral disorders states that “Sensory based therapies are increasingly used by occupational therapists and sometimes by other types of therapists in treatment of children with developmental and behavioral disorders. However, it is unclear whether children who present with sensory-based problems have an actual “disorder” of the sensory pathways of the brain or weather these deficits are characteristics associated with other developmental and behavioral disorders. Because there is no universally accepted framework for diagnosis, sensory processing disorder generally should not be diagnosed. Other developmental and behavioral disorders must always be considered, and thorough evaluation should be completed. Difficulty tolerating or processing sensory information is characteristic that may be seen in many developmental behavioral disorders, including autism spectrum disorders, attention deficit/hyperactivity disorder, developmental coordination disorders and childhood anxiety disorders.”
“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 is limited and inconclusive. Important roles for pediatricians and other clinicians may include discussing these limitations with parents.”
American Academy of Child and Adolescent Psychiatry (AACAP)
A 2014 practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder states that “Studies of sensory oriented interventions, such as auditory integration training (AIT), sensory integration therapy (SIT) and touch therapy/massage, have contained methodological flaws and have yet to show replicable improvements.”
American Occupational Therapy Association (AOTA)
In 2011, AOTA published evidence-based occupational therapy practice guidelines for children and adolescents with challenges in sensory processing and sensory integration (SI). AOTA gave a level C recommendation for SI 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 in a recommendation that occupational therapy practitioners routinely provide the intervention to eligible clients or in no recommendation because the balance of the benefits and harm 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).
American Speech-Language Hearing Association (ASHA)
In 2003, the American Speech-Language-Hearing Association (ASHA) Working Group on Auditory Integration Training issued a report on Auditory Integration Training. The review concluded “Despite approximately one decade of practice in this country, this method has not met scientific standards for efficacy and safety that would justify its inclusion as mainstream treatment for these disorders.”
Sensory integration therapy (SIT) is considered investigational for all indications.
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. Therefore, the use of sensory integration therapy (SIT) is considered investigational.
Auditory integration therapy is considered investigational for all indications.
For auditory integration (AI) 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 evaluated the use of AI therapy for other conditions. Therefore, the use of auditory integration (AI) therapy is considered investigational.
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
- 97533 Sensory Integration Therapy
- 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. J Autism Dev Disord.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.
- Schaaf RC, Benevides TW, Kelly D, Mailloux-Maggio Z. Occupational therapy and sensory integration for children with autism: a feasibility, safety, acceptability and fidelity study. Autism. 2012 May;16(3):321-7.
- American Academy of Pediatrics: Zimmer M & Desch L. Sensory integration therapies for children with developmental and behavioral disorders. Pediatrics. 2012 June; 129(6):1186-9.
- Candian Agency of Drugs and Technologies in Health (CADTH), Rapid Response Report: Sensory Integration Theory Interventions for Children with Autism Spectrum Disorders: Clinical Evidence. February 2, 2011
- American Academy of Child and Adolescent Psychiatry (AACAP), Practice Parameter for the Assessment and Treatment of Children and Adolescents with Autism Spectrum Disorder. 2013 Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP)
- UpToDate. Autism Spectrum Disorders in Children and Adolescents: Behavioral and Educational Interventions. Laura Weissman, M.D., Carolyn Bridgemohan, M.D.. Topic last updated July 16, 2015. www.uptodate.com
- American Academy of Pediatrics, Auditory Integration Training and Facilitated Communication for Autism, Pediatrics 1998;102;431
- American Occupational Therapy Association (AOTA) 2011 Occupational Therapy Practice Guidelines for Children and Adolescents with Challenges in Sensory Processing and Sensory Integration
- American Speech Language Hearing Association (ASHA) 2003 Technical Report Working Group in Auditory Integration Training
- National Institute of Health and Care Excellence (NICE) 2013 Guideline for Autism: The Management and Support of Children and Young People on the Autism Spectrum, Clinical guideline no. 170.
- The Berard AIT Website. Also available at www.berardaitwebsite.com
- 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. PMID 22161380
- 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. PMID 25184475
- 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. Mar-Apr 2007;61(2):254-259. PMID 17436848
- Parham LD, Cohn ES, Spitzer S, et al. Fidelity in sensory integration intervention research. Am J Occup Ther. Mar-Apr 2007;61(2):216-227. PMID 17436844
- Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Sensory integration therapy. TEC Assessment. 1999;Volume 14, Tab 22.
- Case-Smith J, Arbesman M. Evidence-based review of interventions for autism used in or of relevance to occupational therapy. Am J Occup Ther. Jul-Aug 2008;62(4):416-429. PMID 18712004
- Baranek GT. Efficacy of sensory and motor interventions for children with autism. J Autism Dev Disord. Oct 2002;32(5):397-422. PMID 12463517
- 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. May-Jun 2010;64(3):403-414. PMID 20608272
- Case-Smith J, Weaver LL, Fristad MA. A systematic review of sensory processing interventions for children with autism spectrum disorders. Autism. Jan 29 2014. PMID 24477447
- 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. PMID 24214165
- 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. Jan-Feb 2011;65(1):76-85. PMID 21309374
- 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. Mar-Apr 2007;61(2):228-238. PMID 17436845
- Uyanik M, Bumin G, Kayihan H. Comparison of different therapy approaches in children with Down syndrome. Pediatr Int. Feb 2003;45(1):68-73. PMID 12654073
- Parr J. Autism. Clin Evid (Online). 2010;2010. PMID 21729335
- Rossignol DA. Novel and emerging treatments for autism spectrum disorders: a systematic review. Ann Clin Psychiatry. Oct-Dec 2009;21(4):213-236. PMID 19917212
- Myers SM, Johnson CP. Management of children with autism spectrum disorders. Pediatrics. Nov 2007;120(5):1162-1182. PMID 17967921
- Zimmer M, Desch L. Sensory integration therapies for children with developmental and behavioral disorders. Pediatrics. Jun 2012;129(6):1186-1189. PMID 22641765
- Roley SS, Bissell J, Clark GF. Providing occupational therapy using sensory integration theory and methods in school-based practice. Am J Occup Ther. Nov-Dec 2009;63(6):823-842. PMID 20092120
- Volkmar F, Siegel M, Woodbury-Smith M, et.al. Practice parameter for the assessment of children and adolescents with autism spectrum disorder. J Am. Acad Child Adolesc Psychiatry 2014;53(2):237-257
- UpToDate Evaluation and Treatment of Speech and Language Disorders in Children. James Carter MA, CCC-SLP, Karol Musher MA CCC-SLP, Topic last updated April 22, 2015. Also available at www.uptodate.com
Date Reason Action
September 2011 Annual review Policy renewed
September 2012 Annual review Policy renewed
August 2013 Annual review Policy renewed
May 2014 Annual review Policy renewed
April 2015 Annual review Policy revised
March 2016 Annual review Policy renewed
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*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.