Medical Policy: 08.03.04
Original Effective Date: August 2000
Reviewed: March 2020
Revised: March 2019
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Sensory integration therapy (SIT) also known as sensory integrative techniques has been proposed as a treatment of developmental disorders in patients with established dysfunction of sensory processing e.g., children with autism spectrum disorder (ASD), 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. Practitioners have used SIT for years selecting patients who demonstrate a variety of problems, including sensory defensiveness, over-reactivity to environmental stimuli, attention difficulties, and behavioral problems.
Sensory integration therapy techniques are used to organize the sensory system by involvement of full body movements that provide vestibular, proprioceptive and tactile stimulation.
The ultimate goal of sensory integration therapy (SIT) is to improve cognitive, behavioral and social functioning. The therapeutic techniques may include different kinds of equipment such as textured mitts, brushes, balls, large foam pillows or mats, scooter boards, ramps, swings, trapeze bars and bounce pads. 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. 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 or physical therapist with special training from university curricula, clinical practice, and mentorship in the theory, techniques and assessment tools unique to SIT. 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.
The literature on the use of sensory integration therapy (SIT) consists primarily of small case series as well as a small number of comparative studies and systematic reviews. Given the individualized nature of SIT and the potential for confounding due to effects of treatment other than the SIT itself, large comparative studies are needed to demonstrate effectiveness.
In 2014, Shaaf et. al. published an overview of measurement issues in sensory integration. They proposed several change to the outcomes used in sensory integration research, as follows:
Several systematic reviews have addressed the use of sensory integration therapy (SIT) in various clinical conditions.
In 2015, Case-Smith et. al. updated a systematic review on sensory processing interventions, including sensory integration therapy (SIT), which they defined as clinic-based interventions that use sensory-rich, child-directed activities to improve a child’s adaptive responses to sensory experiences, and sensory-based interventions (defined as adult-directed sensory modalities applied to the child to improve behaviors associated with modulation disorders), for children with autism spectrum disorder (ASD) with concurrent sensory processing problems. This review was designed to focus on interventions that activate the somatosensory and vestibular systems for patients with ASD with co-occurring sensory processing problems. Nineteen studies published since 2000 were included, 5 of which evaluated SIT in patients with ASD and sensory processing disorders. Two studies reviewed were randomized controlled trials (RCTs); both were small (n=20 and n=17 in the SIT groups). The authors noted that the studies showed low or low-to-moderate effects and concluded that it is premature to draw conclusions as to whether SIT for children with ASD, which is designed to support a child’s intrinsic motivation and sense of internal control, is ultimately effective.
In 2015, Brondino et. al. published a systematic review of complementary and alternative therapies for autism, which included sensory integration therapy (SIT) and auditory integration therapy (AIT). Regarding SIT for autism spectrum disorder (ASD) treatment, reviewers identified 4 trials, including the RCT reported by Pfeiffer et al (described below), and additional studies published in 1983, 2008, and 2011, with sample sizes of 18, 30, and 50, respectively. All 4 studies reported significant improvements in autistic core symptoms, including communication, social reciprocity, and motor activity. However, reviewers noted that 2 studies did not use a standardized form of SIT, and 2 did not use standardized outcome measures.
In 2015, Watling and Hauer published a systematic review of Ayres Sensory Integration (ASI) and sensory-based interventions for individuals with autism spectrum disorder (ASD). Reviewers described ASI as a play-based method that “uses active engagement in sensory-rich activities to elicit the child’s adaptive responses and improve the child’s ability to successfully perform and meet environmental challenges.” The therapy is individualized by the therapist in response to an initial assessment. Sensory-based interventions are described as “applying adult-directed sensory modalities to the child with the aim of producing a short-term effect on self-regulation, attention, or behavioral organization.” Twenty-three articles met reviewers’ inclusion criteria, 3 of which were systematic reviews and 5 of which were RCTs. Overall, 4 studies evaluated ASI and the remaining 18 evaluated sensory-based interventions. Of the 4 studies evaluating ASI, 3 were RCTs, including the studies by Pfeiffer et al and Schaaf et al (described below). Findings from 1 RCT included significant improvement in individualized goals, improved sleep, decreased ASD mannerisms, and reduced caregiver burden.
Barton et. al. (2015) published a systematic review and the purpose of this review was to conduct a comprehensive and methodologically sound evaluation of the efficacy of sensory-based treatments for children with disabilities. Methods for this review were registered with PROSPERO (CRD42012003243). Thirty studies involving 856 participants met inclusion criteria and were included in this review. Considerable heterogeneity was noted across studies in implementation, measurement, and study rigor. The research on sensory-based treatments is limited due to insubstantial treatment outcomes, weak experimental designs, or high risk of bias. Although many people use and advocate for the use of sensory-based treatments and there is a substantial empirical literature on sensory-based treatments for children with disabilities, insufficient evidence exists to support their use.
In 2019, Kilroy et. al. revisted Ayres theories of autism and sensory integration which concluded, further research is necessary to better understand the relationship between neural abnormalities in autism spectrum disorder (ASD) and therapeutic approaches intended to ameliorate sensory impairment symptoms and to promote easier participation in everyday life activities. To our knowledge, no published studies have specifically investigated the neural response to Ayres sensory integration therapy in individuals with ASD. Research is needed to examine whether intervention using a sensory integration approach will help improve sensory registration and/or modulation impairments in ASD by developing a more efficient network connectivity.
In 2014, Schaaf et al reported results from a randomized trial of a manualized intervention for sensory difficulties in children with autism spectrum disorder (ASD). The trial enrolled 32 children from a convenience sample of eligible families with children ages 4 to 8 years who had a diagnosis of ASD and demonstrated difficulty processing and integrating sensory information as measured by the Sensory Profile or the Sensory Integration and Praxis Test. Subjects were randomized to usual care or to an intervention described as following the principles of ASI. The intervention was delivered by 3 licensed occupational therapists experienced working with children with ASD. The primary outcome was Goal Attainment Scaling (GAS), a systematic process for identifying goals relevant to individuals and their families that has been used to evaluate patients with ASD. Sample goals include: “Improve auditory process as a basis for sleeping through the night without getting out of bed for 7–8 h per night” and “Decrease oral sensitivity and will try 5 new foods.” Each goal is associated with a scale for level of attainment. For the primary outcome, the intervention group had a significantly higher goal achievement score than the control group (mean, 56.53 [n=17] vs 42.72 [n=14], p=0.003). Change in functional skills did not differ significantly between groups, but intervention group subjects had significantly greater improvements in the 2 subscales of self-care caregiver assistance (p=0.008) and social function caregiver assistance (p=0.039). The groups did not differ in terms of autistic or adaptive behaviors. Strengths of this trial were its use of a protocolized intervention and its attempt to use an outcome measure relevant to patients and families. However, further replication in a larger sample of patients is required.
In a pilot study reported in 2011 by Pfeiffer et. al., the purpose of this study was to establish a model for randomized controlled trial research, identify appropriate outcome measures and address the effectiveness of sensory integration (SI) interventions in children with autism spectrum disorders (ASD). Children ages 6-12 with ASD were randomly assigned to a fine motor or SI treatment group (18 treatments over 6 weeks). Pretests and post-tests measured social responsiveness, sensory processing, functional motor skills and social-emotional factors. The results of this study were mixed yet demonstrated significant changes in the autistic mannerisms (a component of social responsiveness) and significant progress toward individualized goals in the areas of sensory processing and regulation, social-emotional function, and FM skills. No significant differences were found in the scores on the SPM (sensory processing measure) or the QNST-II (Quick Neurological Screening Test). A subsequent analysis did identify that significantly more children could complete or partially complete the QNST-II after intervention. The authors concluded this study provides preliminary support for using sensory integration (SI) interventions in children with ASD, although further research is necessary. Results identified significant progress toward individualized goals and a decrease in autistic mannerisms after SI interventions, although no significant changes were found on the other measures. Results suggest implementing interventions that are generalized to home and community settings, using tools that allow for individualized sensitive measurement in future studies, and completing future studies with a larger sample.
Due to the individual nature of sensory integration 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 from sensory integration therapy comes from randomized trials. Although some of the studies demonstrated some improvements on subsets of outcomes measured, the studies are limited by sizes, heterogeneous 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 sensory integration therapy.
For adult patients, sensory integration therapy has been used for acquired sensory problems resulting from head trauma, illness, or acute neurologic events including cerebrovascular accidents. Sensory integration techniques are not appropriate for patients with progressive neurological conditions without potential for functional adaptation. Therapy is not considered a cure for sensory integrative impairments but is used to facility the development of the patient’s ability to process sensory input differently. Research studies are lacking for the adult population and sensory integration therapy.
Auditory integration therapy (AIT) (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. AIT 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.
Auditory integration therapy (AIT) refers to listening to music that has been computer modified to remove frequencies to which an individual demonstrates hypersensitivities and to reduce the predictability of auditory patterns. The individual listens per headphones to a program of specifically filtered and modulated music with wide frequency range. A special device is used to modify the music for the treatment sessions. The treatment program consists of 20 half-hour sessions during a 10 to 12 day period, with two sessions daily. Auditory thresholds are determined via audiograms. The audiogram is then reviewed for evidence of hyperacusis (i.e. an abnormal sensitivity to sound). A clinical history of sound sensitivities and behavior is also reviewed. Audiograms are repeated midway and at the end of the training session to document progress and to determine whether further treatment sessions are necessary. AIT is usually performed by a speech-pathologist or audiologist.
Although at least three AIT methods currently exist, the Berard method has emerged as the most commonly used in the United States and has been described most often in professional literature which is limited. The Educational Audiology Association (EAA) issued a position statement regarding auditory integration therapy, which stated: Auditory integration therapy has not been proven to be a viable treatment for any disability. On inconsistent, uncontrolled, anecdotal evidence has been provided to support claims of changes in auditory performance. Educations audiologists must advise parents of the risk of experimental procedures such as auditory integration therapy, and of their right to request a forthright statement of expected outcomes by providers of such experimental methods. Furthermore, the Educational Audiology Association warns that without controls to protect against excessively loud auditory stimuli, auditory integration therapy may cause harm to a child’s auditory system.
Although auditory integration therapy (AIT) has been proposed as a therapy for a number of neurobehavioral disorders, the largest body of evidence, including systematic reviews, relates to its use in autism spectrum disorder (ASD).
A 2011 Cochrane review evaluated auditory integration therapy (AIT) or other methods of sound therapy in individuals with autism spectrum disorders (ASD). Randomized controlled trials involving adults or children with autism spectrum disorders. Treatment was auditory integration therapy or other sound therapies involving listening to music modified by filtering and modulation. The outcomes were changes in core and associated features of autism spectrum disorders, auditory processing, quality of life and adverse events. Six randomized controlled trials (RCTs) of auditory integration therapy (AIT) and one of Tomatis therapy, involving a total of 182 individuals (age range, 3-39 years). For most studies, the control condition was listening to unmodified music for the same amount of time as the active treatment group. Allocation concealment was inadequate for all studies, and 5 trials had fewer than 20 participants. Meta-analyses could not be conducted. Three studies did not demonstrate any benefit of AIT over control conditions, and 3 studies had outcomes of questionable validity or outcomes that were not statistically significant. The authors concluded, that there is no evidence that auditory integration therapy or other sound therapies are effective as treatments for autism spectrum disorders. As synthesis of existing data has been limited by the disparate outcome measures used between studies, there is not sufficient evidence to prove that this treatment is not effective. However, of the six studies including 182 participants that have been reported to date, only two (with an author in common), involving a total of 35 participants, report statistically significant improvements in the auditory integration therapy group and for only two outcome measures (Aberrant Behaviour Checklist and Fisher's Auditory Problems Checklist). As such, there is no evidence to support the use of auditory integration therapy at this time.
In 2015 systematic review examining complementary and alternative therapies for autism spectrum disorder (ASD), Brondino et al (described above) identified the same 6 RCTs of in auditory integration therapy (AIT) included in the 2011 Cochrane review. Like the Cochrane review, Brondino et al concluded that the largest studies did not report improvements with AIT.
Weitlauf et. al. (2017) in a systematic review evaluated the effectiveness and safety of interventions targeting sensory challenges in autism spectrum disorder (ASD). Twenty-four studies, including 20 randomized controlled trials (RCTs), were included. Only 3 studies had low risk of bias. Populations, interventions, and outcomes varied. Limited, short-term studies reported potential positive effects of several approaches in discrete skill domains. Specifically, sensory integration-based approaches improved sensory and motor skills-related measures (low SOE). Environmental enrichment improved nonverbal cognitive skills (low SOE). Studies of auditory integration-based approaches did not improve language (low SOE). Massage improved symptom severity and sensory challenges in studies with likely overlapping participants (low SOE). Music therapy studies evaluated different protocols and outcomes, precluding synthesis (insufficient SOE). Some positive effects were reported for other approaches, but findings were inconsistent (insufficient SOE). Limitations are the studies were small and short-term, and few fully categorized populations. The authors concluded, some interventions may yield modest short-term (<6 months) improvements in sensory and ASD symptom severity-related outcomes; the evidence base is small, and the durability of the effects is unclear. Although some therapies may hold promise, substantial needs exist for continuing improvements in methodologic rigor.
For individuals who have developmental and behavioral disorders who receive auditory integration therapy (ATI), the evidence include randomized controlled trials (RCTs) and systematic reviews of these trials. For auditory integration therapy (AIT), the largest body of literature relates to its use in autism spectrum disorder (ASD). Several systematic reviews of AIT in the treatment of autism have found limited evidence to support its use. No comparative studies were identified that evaluated the use of AI therapy for other conditions. Further well designed clinical trials are needed regarding auditory integration therapy (AIT) in order to determine the clinical effectiveness of this intervention. The evidence is insufficient to determine the effects of the technology on net health outcomes.
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.”
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.”
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).
In 2008, the American Speech-Language-Hearing Association (ASHA) Working Group updated their review on processing disorders:“In the most recent technical report addressing the value of auditory integration therapy (AIT) in treating various communication, behavioral, emotional and learning disorders and concluded that 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.”
Recommendations for future research: The use of auditory training to produce physiological and/or auditory behavioral change could one day provide important information about the existence of auditory processing disorders (APD) and treatment efficacy. Measuring both behavioral and physiological changes (rather than just physiological) is important and should be continued. Additional research of this type should include functional measures of listening and long-term follow-up testing.
Sensory integration therapy (SIT) and auditory integration therapy (AIT) is considered investigational for all indications. The evidence is insufficient to determine the effects of this therapy on net health outcomes.
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