National Medical Policy

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1 National Medical Policy Subject: Physical and Occupational Therapy Policy Number: NMP218 Effective Date*: June 2005 Updated: October 2014 This National Medical Policy is subject to the terms in the IMPORTANT NOTICE at the end of this document For Medicaid Plans: Please refer to the appropriate Medicaid Manuals for coverage guidelines prior to applying Health Net Medical Policies The Centers for Medicare & Medicaid Services (CMS) For Medicare Advantage members please refer to the following for coverage guidelines first: Use Source Reference/Website Link National Coverage Determination (NCD) National Coverage Manual Citation Guidance/Guidance/Manuals/downloads/bp102c15.pdf Chapter 15 Section 200 X Local Coverage Determination (LCD)* Outpatient Occupational Therapy: Outpatient Physical Therapy: X Article (Local)* Response to Comments: J1 Part A Rehabilitation Local Coverage Determinations (LCDs): Outpatient Occupational Therapy; Supplemental Instructions Article: X Other Medicare Benefit policy Manual: Coverage of Extended Care (SNF) Services Under Hospital Insurance: 2c08.pdf Home Health Services: 2c07.pdf Physical and Occupational Therapy Oct 14 1

2 None Comprehensive Outpatient Rehabilitation Facility (CORF) Coverage: 2c12.pdf Will Medicare pay for outpatient physical, occupational or speech therapy? MedicareInteractive.org 2011: counselor&page=script&slide_id=353 Use Health Net Policy Instructions Medicare NCDs and National Coverage Manuals apply to ALL Medicare members in ALL regions. Medicare LCDs and Articles apply to members in specific regions. To access your specific region, select the link provided under Reference/Website and follow the search instructions. Enter the topic and your specific state to find the coverage determinations for your region. *Note: Health Net must follow local coverage determinations (LCDs) of Medicare Administration Contractors (MACs) located outside their service area when those MACs have exclusive coverage of an item or service. (CMS Manual Chapter 4 Section 90.2) If more than one source is checked, you need to access all sources as, on occasion, an LCD or article contains additional coverage information than contained in the NCD or National Coverage Manual. If there is no NCD, National Coverage Manual or region specific LCD/Article, follow the Health Net Hierarchy of Medical Resources for guidance. Current Policy Statement: Physical therapy (PT) and Occupational therapy (OT) services are considered medically necessary when ordered by a physician (unless this is in conflict with state or other regulatory processes that allows direct access for these services: please refer to state specific guidelines) and all the following criteria are met: 1. Services are rehabilitative in nature and designed to prevent disability or improve or restore functions that have been lost as a result from disease, illness, injury, congenital abnormality or surgery, and 2. Services are at a level of complexity and sophistication or the condition of the patient is such that the services required can be safely and effectively performed only by a qualified therapist, or under the supervision of a qualified physician/therapist, and 3. There is an expectation that the therapy will result in a practical improvement or prevention of disability in the level of functioning within a reasonable and predictable period of time, and 4. Services must relate directly to a treatment regimen for the specific condition, illness or injury being treated, and 5. Services must be currently accepted standards of medical practice and specific and effective treatment for the patient s existing condition, and 6. The treatment goals and subsequent documentation of treatment results should specifically demonstrate that these services are contributing to such improvement. Physical and Occupational Therapy Oct 14 2

3 NOTE: Physical and occupational therapy for comorbid physical impairments in individuals with severe mental illness, including but not limited to autism spectrum disorders and other pervasive developmental disorders, are considered medically necessary when criteria for physical and occupational therapy are met. Indications: 1. Indications for PT and OT include the period immediately following any of the following acute conditions (not an all-inclusive list): Traumatic injuries Surgical procedures Cerebral vascular hemorrhage or thrombosis Short term, medically imposed complete bed rest for time-limited conditions in order to maintain strength and mobility, such as with preterm labor Pregnancy related severe musculoskeletal conditions that interfere with activities of daily living Acute episodes or exacerbations of medical conditions Acute exacerbation of chronic conditions may be considered when significant improvement can be achieved and sustained as a result of the therapy 2. Indications for continued services include documentation of all of the following: Patient s physician must approve the therapist s request for continued therapy Indication of restorative potential Significant progress is being made toward the established goals Significant progress is expected in a reasonable and predictable period of time 3. Indications for discontinuation of PT or OT include any of the following: Documentation by registered physical, occupational therapist, or patient s physician that the patient has reached maximum potential for improvement Patient has achieved stated goals No documented evidence of measurable improvement during the last three treatments Medical condition precludes therapy Patient refuses treatment 4. Indications for home PT or OT for any diagnosis include all of the following: o Documentation of homebound status Maintenance Program Maintenance programs are intended to prevent deterioration when this can occur as part of the natural progression of the condition, disorder or illness and begin when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur. If the expected results are insignificant in relation to the extent and duration of physical therapy services that would be required to achieve those results, the physical therapy would not be reasonable and necessary, and thus would not be covered skilled physical therapy Physical and Occupational Therapy Oct 14 3

4 services. Examples include therapy that is solely to improve endurance and strength, range of motion that can be administered by non-skilled persons and general exercise programs to promote overall fitness. In maintenance therapy, the skills of a therapist are necessary to maintain, prevent, or slow further deterioration of the patient s functional status, and the services cannot be safely and effectively carried out by the beneficiary personally, or with the assistance of non-therapists, including unskilled caregivers Not Medically Necessary (Physical Therapy) Medical necessity of physical therapy has not been demonstrated for: Chronic conditions without acute exacerbation (for example, chronic back syndrome, post polio syndrome, multiple sclerosis, and cerebral palsy) that do not meet the definition of maintenance therapy or habilitative services Pulmonary conditions treated with diathermy, ultrasound, or heat treatments Treatment of upper motor neuron disorders by electrical nerve stimulation Repetitive exercise to improve gait, maintain strength and endurance, and assistive walking in weak or unstable patients that do not meet the definition of maintenance therapy or habilitative services Exercise programs, maintenance therapy, repetitive activities that an individual can self-practice independently or with a caregiver Range of motion and passive exercises that are not related to restoration of a specific loss of function that do not meet the definition of maintenance therapy or habilitative services Occupational Therapy The American Occupational Therapy Association (AOTA) defines occupational therapy (OT) as the use of purposeful activity or interventions designed to achieve functional outcomes which promote health or prevent injury or disability. OT services include diagnostic evaluation and therapeutic intervention designed to improve, develop, correct, rehabilitate, or prevent the worsening of functions that affect the activities of daily living (ADL) that have been lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital anomalies, or injuries. Occupational therapy programs are designed to improve quality of life by recovering competence and preventing further injury or disability, and to improve the individual s ability to perform tasks required for independent functioning, so that the individual can engage in ADLs. ADLs include bathing, dressing, eating, feeding, functional mobility, personal device care, personal hygiene, grooming, and toilet hygiene. Occupational therapy does not include diversional, recreational, and vocational therapies (such as hobbies, arts and crafts). Medical necessity of occupational therapy has not been demonstrated in the medical literature for: Mental retardation or dyslexia Attention deficit disorders and associated behavior problems Dysgraphism (inability to write properly) or loss of fine motor control Sensory and auditory integration therapies for the management of individuals with various communication, behavioral, emotional, developmental and learning disorders. Habilitative Services (January 1, 2014) Physical and Occupational Therapy Oct 14 4

5 Coverage for habilitative services and/or therapy is limited to Medically Necessary services that assist an individual in partially or fully acquiring or improving skills and functioning and that are necessary to address a health condition, to the maximum extent practical, when provided by a Preferred Provider, licensed physical, speech or occupational therapist or other contracted provider, acting within the scope of his or her license, to treat physical and mental health conditions, subject to any required authorization. The services must be based on a treatment plan authorized, as required by Health Net. Not Medically Necessary Habilitative services Examples of health care services that are not habilitative include, but are not limited to, respite care, day care, recreational care, residential treatment, social services, custodial care, or education services of any kind, including, but not limited to, vocational training. Aquatic Therapy Aquatic therapy may be considered medically necessary for individuals who have a documented musculoskeletal functional loss (joint range of motion, flexibility, strength, or mobility) which has resulted from a disease, injury or surgery and when an aquatic environment is determined to be clinically advantageous over land-based therapy. Aquatic therapy allows for exercise in a gravity-reduced, nonweight-bearing environment performed for muscle strengthening. Aquatic therapy must require the skills of a physical therapist. Aquatic therapy as a maintenance program and general exercise program (e.g., water walking/jogging) in the absence of documentation that supports skilled intervention is considered not medically necessary. Aquatic therapy is considered experimental and investigational for the treatment of asthma and all other non-musculoskeletal indications (e.g., autism) because its effectiveness for non-musculoskeletal indications has not been established. Documentation Requirements for Rehabilitative, Habilitative and Maintenance Services The following care plan documentation may be requested: 1. Physical and occupational therapy should be provided in accordance with an ongoing, written plan of care. The purpose of the written plan of care is to assist in determining medical necessity. 2. The plan of care should include sufficient information to determine the medical need of treatment. The plan of care should be specific to the diagnosis, presenting symptoms, and findings of the PT/OT evaluation. 3. The plan of care should include: The date of onset or exacerbation of the disorder/diagnosis; Specific statements of long-term and short-term goals; Quantitative objectives measuring current age-adjusted level of functioning; A reasonable estimate of when the goals will be reached; The specific treatment techniques and/or exercises to be used in treatment; and The frequency and duration of treatment. Physical and Occupational Therapy Oct 14 5

6 5. The plan of care should be ongoing (i.e., updated as the patient's condition changes) 6. The patient should be reevaluated every three months, and there should be documentation of progress made toward the goals of therapy. Codes Related To This Policy NOTE: The codes listed in this policy are for reference purposes only. Listing of a code in this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the benefit documents and medical necessity criteria. This list of codes may not be all inclusive. On October 1, 2015, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. Health Net National Medical Policies will now include the preliminary ICD-10 codes in preparation for this transition. Please note that these may not be the final versions of the codes and that will not be accepted for billing or payment purposes until the October 1, 2015 implementation date. ICD-9 Codes Note: This list of codes may not be all-inclusive Hyperkinetic syndrome of childhood Reflex sympathetic dystrophy Other conditions of brain Disorders of the peripheral nervous system Late effects of cerebrovascular disease, hemiplegia/hemiparesis, monoplegia, and other paralytic syndrome Other late effects of cerebrovascular disease, ataxia Atherosclerosis of the extremities with ulceration Atherosclerosis of the extremities with gangrene Varicose veins of lower extremities with ulcer Varicose veins of lower extremities with ulcer and inflammation Venous (peripheral) insufficiency, unspecified Chronic ulcer of skin Diseases of the musculoskeletal system and connective tissue Abnormality of gait Lack of coordination Transient paralysis of limb Injury ICD-10 Codes (too numerous to list) F90- F90.9 Attention-Deficit Disorders F93- F93.9 Emotional disorders with onset specific to childhood G00-G99 Diseases of the nervous system L00-L99 Diseases of the skin and subcutaneous tissue M00-M99 Diseases of the musculoskeletal system and connective tissue S00-T88 Injury, poisoning and certain other consequences of external causes Physical and Occupational Therapy Oct 14 6

7 CPT Codes Note: This list of codes may not be all-inclusive Physical Therapy Evaluation Physical Therapy Re-Evaluation Occupational therapy evaluation Occupational therapy re-evaluation Application of a modality to one or more areas; hot or cold packs Application of a modality to one or more areas; traction mechanical Application of a modality to one or more areas; electrical stimulation (unattended) Application of a modality to one or more areas; vasopneumatic devices Application of a modality to one or more areas; paraffin bath Application of a modality to one or more areas; microwave (Code deleted 12/31/06) To report use Application of a modality to one or more areas; whirlpool Application of a modality to one or more areas; diathermy Application of a modality to one or more areas; infrared Application of a modality to one or more areas; ultraviolet Application of a modality to one or more areas; electrical stimulation, (manual), each 15 minutes Application of a modality to one or more areas; iontophoresis, each 15 minutes Application of a modality to one or more areas; contrast baths, each 15 minutes Application of a modality to one or more areas; ultrasound, each 15 minutes Application of a modality to one or more areas; Hubbard tank, each 15 minutes Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing) Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and /or tapotement (stroking, compression, percussion) Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by provider, each 15 minutes Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each 15 minutes Orthotic(s) management and training (including assessment and fitting or trunk, each 15 minutes Posthetic training, upper and/or lower extremities, each 15 minutes HCPCS Codes Physical and Occupational Therapy Oct 14 7

8 G0151 Services of physical therapist in home or health setting, each 15 minutes ( revised in 2011) G0152 Services of occupational therapist in home health setting, each 15 minutes (revised in 2011) S9129 Occupational therapy, in the home, per diem S9131 Physical therapy; in the home, per diem Revised HCPCS Codes 2011 G0151 Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes G0152 Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes Scientific Rationale Update September 2014 In 2008, Case-Smith and Arbesman reviewed 49 articles to determine the effect of occupational therapy (OT) interventions for individuals who have autism spectrum disorder. Of these studies, 8 related to sensory integration and sensory-based interventions. All were level I (i.e., randomized controlled trials, systematic reviews, and meta-analyses). Authors noted, Limitations of the studies included small sample size and lack of control groups. Although each of these studies had positive findings, when combined, the evidence remains weak and requires further study. In 2008, Smania et al. evaluated whether balance exercises performed under various sensory input manipulations can improve postural stability and/or walking ability in a small study of 7 patients who suffered a stroke. Patient performance was assessed before, immediately after and one week after treatment. After treatment, balance and walking speed significantly increased and this improvement was maintained for one week. The study design (case series) did not allow for any generalizable conclusions. Statistical methodologies were limited by the small sample size. Conclusions about relative benefit/risk could not be reached due to the lack of a control and/or a comparative group. The follow-up at one week post-treatment did not allow for assessment of intermediate and long-term outcomes. In 2009, Wuang et al. compared the effect of sensory integration therapy (SIT), neurodevelopmental treatment (NDT), and perceptual-motor (PM) approach on children with mild intellectual disability. A total of 120 children were randomly assigned to one treatment; another 40 children served as control participants. After intervention, the treatment groups significantly outperformed the control group on almost all measures. The sensory integration (SI) group demonstrated a greater pretest-post test change on fine motor, upper-limb coordination, and SI functioning. The PM group showed significant gains in gross motor skills, whereas the NDT group had the smallest change in most measures. Confidence in the conclusions about the efficacy of SI for improvements in sensorimotor function among children with mild mental retardation was reduced by the restricted age range (ages 7 to 8) of the study sample, a nonequivalent control group, differences in the intensity and frequency of home practice sessions, and a lack of long-term follow-up. Stephenson et al. [2009] reviewed 7 studies examining weighted vests. The investigators concluded that while there is only a limited body of research and a number of methodological weaknesses, on balance, indications are that weighted vests are ineffective. Physical and Occupational Therapy Oct 14 8

9 Hodgetts et al. [2010] conducted a small, randomized, blinded study measuring the effects of wearing a weighted vest on stereotyped behaviors and heart rate for 6 children with autism in a classroom. Weighted vests did not decrease motoric stereotyped behaviors in any participant. Verbal stereotyped behaviors decreased in one participant. The use of weighted vests to decrease stereotyped behaviors or arousal in children with autism in the classroom was not supported. Research has consistently failed to uncover any sound scientific evidence that SIT produces meaningful outcomes for people with developmental disorders. Williames & Erdie [2009] conducted an extensive review of the medical literature and concluded, SI therapy is a popular treatment for multiple conditions, but strong empiric evidence in a standard case-control format does not yet support its efficacy. Thus, well-designed scientific studies are needed to determine whether SI dysfunction is indeed a disorder, and if so, whether therapy is effective or necessary. A small study comparing sensory integration therapy to behavioral intervention in children who have autism spectrum disorder found that the latter was more effective in reducing challenging behavior and self-injurious behavior [Devlin 2011]. Lang et al. [2012] analyzed 25 published intervention studies involving the use of SIT in 217 individuals who had autism spectrum disorder. Of these, only 3 suggested that SIT was effective. In contrast, 8 studies reported mixed results, and 14 found no benefit following SIT. Of the three studies that reported positive findings, all three were classified at the lowest level of certainty due to serious methodological limitations. Sensory integration dysfunction or sensory processing disorder remains an unproven diagnosis and there is insufficient evidence in the peer-reviewed medical literature to support therapy being effective. Central/Auditory Processing Disorder (APD) is a controversial and unproven entity in which individuals reportedly have difficulty processing or interpreting auditory information. These patients have normal hearing. Children diagnosed with APD often do not recognize subtle differences between sounds in words, even though the sounds themselves are loud and clear. These problems occur more frequently in noisy environments or when listening to complex information. Thus, another common name for this alleged entity is "word deafness." A review of the peer-reviewed medical literature finds mostly poorly designed studies and flawed methodology. Although the American Speech-Language-Hearing Association published a Technical Report on APD in 2005, it is based on theory and opinion rather than being evidence based. Since the 1960s, APD remains a modality specific diagnosis (i.e., one made by audiologists or speech-language pathologists). Rather than being a stand-alone diagnosis, APD is always part of a bigger picture including attention-deficit/hyperactivity disorder, autism spectrum disorder, learning disability (eg dyslexia), or language disorder. There are no adequate controlled studies either supporting the existence of APD as a distinct and definable entity or clearly demonstrating the effectiveness of APD therapy compared to placebo. Research has consistently failed to uncover any sound scientific evidence that APD therapy produces meaningful outcomes for people with developmental disorders. We need well-designed scientific studies to determine whether APD is indeed a disorder, and if so, whether therapy is effective or necessary. Until then, APD and its treatments remain unproven. In a thorough review of the recent literature, McArthur (2009) found that nonspeech training and simple speech training treats APDs but does not treat poor reading, Physical and Occupational Therapy Oct 14 9

10 spoken language, or attention. In other words, therapy for APD has no impact on academics. Auditory integration training (AIT) is a technique for improving abnormal sound sensitivity in individuals that have autism, hyperactivity, APD, and other behavior and learning disabilities. Two half-hour daily sessions of exposure to electronically modified music over 10 days allegedly help retrain the ear s perception of auditory stimuli. Of six randomized controlled trials with varying outcome measures and methodological quality, three yielded some improvement and three yielded no benefit of AIT over control conditions (e.g., listening to unmodified music). In 2010, Moore et al. randomly evaluated 1469 school-aged children for APD. Caregivers completed questionnaires regarding their child s listening and communication skills. Children completed a battery of audiometric, auditory processing (AP), speech-in-noise, cognitive (IQ, memory, language, and literacy), and attention (auditory and visual) tests. AP improved with age. Poor-for-age AP was significantly related to poor cognitive, communication, and speech-in-noise performance. Presenting symptoms of APD were largely unrelated to auditory sensory processing. Response variability and cognitive performance were the best predictors of poor communication and listening. Authors suggest that APD is primarily an attention problem. Fey et al. (2011) systematically reviewed 28 electronic databases. Of 192 articles, only 25 met their criteria for analysis for interventions for APD in school-aged children. These studies were categorized by research phase (e.g., exploratory, efficacy) and ranked on a standard set of quality features related to methodology and reporting. The authors concluded, there is weak evidence to suggest that intensive, short-term interventions (i.e., traditional auditory interventions, Fast ForWord, and Earobics) may be associated with improved auditory functioning (and) there is less evidence that these same interventions affect the spoken and written language performance of children with APD. There is lack of sound scientific evidence in the medical research to indicate that treatment for APD produces meaningful outcomes for people with developmental disorders. Scientific Rationale Update February 2014 In March 2012, the American Academy of Pediatrics (AAP) published a policy statement in Pediatrics stating 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. Sensory-based therapies involve activities that are believed to organize the sensory system by providing vestibular, proprioceptive, auditory, and tactile inputs. Brushes, swings, balls, and other specially designed therapeutic or recreational equipment are used to provide these inputs. However, it is unclear whether children who present with sensory-based problems have an actual disorder of the sensory pathways of the brain or whether 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 a thorough evaluation should be completed. Difficulty tolerating or processing sensory information is a characteristic that may be seen in many developmental behavioral disorders, Physical and Occupational Therapy Oct 14 10

11 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 therapy is limited and inconclusive. Important roles for pediatricians and other clinicians may include discussing these limitations with parents, talking with families about a trial period of sensory integration therapy, and teaching families how to evaluate the effectiveness of a therapy. Pfeiffer et al. (2011) evaluated the effectiveness of sensory integration (SI) interventions in 37 six thru twelve year old children with autism spectrum disorders (18) and unspecified pervasive developmental disorders (16). The children were randomly assigned to either a fine motor or SI group and received 18 treatments over 6 weeks. Results such as sensory processing and regulation, functional motor and socio-emotional skills were evaluated by parents and teachers and thru various formalized tests such as the Social Responsiveness Scale, Sensory Processing Measure (SPM) or the Vineland Adaptive Behavior Scales. The authors concluded that there was some evidence that autistic mannerisms improved compared to controls but the effect was small, and the study is limited in that the sample size was small and follow-up period was short. In a systematic review, May-Benson and colleagues (2010) evaluated the literature on the effectiveness of SIT on the ability of children with learning or reading disabilities and difficulty processing and integrating sensory information. The review identified 27 research studies (13 Level-l randomized trials) that met the inclusion criteria. Most of the studies had been performed in children; there were 2 case reports/small series on the effect of sensory integration therapy in children with autism. Results suggested the SIT may result in positive outcomes in sensori-motor skills and motor planning; socialization, attention, and behavioral regulation; reading-related skills; participation in active play; and achievement of individualized goals. Gross motor skills, self-esteem, and reading gains may be sustained from 3 months to 2 years. The authors noted that the findings may be because of small sample sizes, variable interventions and selection of outcomes that may not be meaningful to clients and families or may not change with amount of treatment provided. The authors stated that replication of findings with methodologically and theoretically sound studies is needed to support current findings. Scientific Rationale Update July 2010 Aquatic Therapy Aquatic therapy is an active therapeutic intervention in which the aquatic environment provides buoyancy, increased resistance (i.e., viscosity) and warmth. The advantage of buoyancy is direct: when a person enters the water, there is an immediate reduction in the effect of gravity on the body. The advantage of viscosity of water is indirect: when the person moves through the water, resistance is felt. This is also referred to as accommodating resistance because it matches the individual's applied force or effort. Because the resistance of the water equals the force exerted, the likelihood of exacerbation or re-injury is reduced dramatically. Advocates of aquatic therapy have proposed that water allows ease of active movement, trunk stabilization, relaxation of spastic muscles, improved circulation, strengthening and functional activity training. Physical and Occupational Therapy Oct 14 11

12 Scientific Rationale Update February 2009 Sensory processing disorder is also known as sensory integration disorder or sensory integration dysfunction. The ongoing relationship between behavior and brain functioning, and distinguishing between these, is the process called sensory integration (SI), a theory that was first pioneered by A. Jean Ayres, Ph.D., OTR in the 1960s. Children with SI dysfunction are theorized to have a disorder involving the reception and integration of sensory information from their environment. This disorder could cause academic difficulties that might be initially diagnosed as a learning disability. In order to be classified as having SI disorders, therapists believe that learningdisabled children must display symptoms such as problems with motor function or physical coordination. These children are often described as clumsy, but standardized testing must reveal difficulties in the processing of vestibular, proprioceptive, or tactile stimuli. Proponents of SI therapy believe that SI dysfunctions contribute to learning disabilities since up to 70% of children with learning disabilities have SI disorders. Factors that contribute to SI disorders could include premature birth, autism and other developmental disorders, learning disabilities, delinquency and substance abuse due to learning disabilities, stress-related disorders, and brain injury. Two of the biggest contributing conditions are autism and attention-deficit hyperactivity disorder (ADHD). In addition, children who have sensory integration dysfunction may be unable to respond to certain sensory information by planning and organizing what needs to be done in an appropriate and automatic manner. This may cause a primitive survival technique called "fright, flight, and fight," or withdrawal response, which originates from the "primitive" brain. This response often appears extreme and inappropriate for the particular situation. Many types of dysfunction have been postulated to occur in individuals with assumed SI disorders. Although the following classifications have been criticized as arbitrary and their definitions change from one publication to another, these are the general areas in which a child is tested to support the diagnosis of SI dysfunction: (1) dysfunction in the vestibular system, usually indicated by a decreased duration of nystagmus (a repetitive eye motion, following spinning of the child); (2) apraxia (a disorder in planning and executing motor acts, identified based on difficulty with imitating the posture of another person); (3) disorders in space perception, which may cause the child to stand too close to another child; (4) auditory or language problems; and (5) tactile defensiveness, which is defined as physical or emotional discomfort when touched by an examiner during tests of tactile perception. Numerous neuropsychological tests have been developed to evaluate levels of dysfunction with relation to these five categories of SI disorders, including the Southern California SI Tests, the Southern California Postrotary Nystagmus Test, and the SI and Praxis Tests. These tests of dysfunction are lengthy, they are made up of multiple subtests, and they are administered by individuals who are certified by a private organization, SI International (Torrance, CA). Another assessment tool developed to evaluate SI function is the DeGangi-Berk test. One of the proposed deficits measured by some of these batteries is hyporeactive postrotary nystagmus, also known as hyponystagmus. Postrotary nystagmus refers to the normal oscillating Physical and Occupational Therapy Oct 14 12

13 eye movements that follow abrupt cessation of spinning. These eye movements reflect the normal function of the semicircular canals within the middle ear, a component of the vestibular system. Hyponystagmus refers to a decreased duration of nystagmus following spinning. Proponents of SI theory consider children with hyponystagmus and disorders such as learning disabilities to be candidates for SI therapy. SI therapy was originally developed for and has been administered to children with cerebral palsy; however, most of the research and debate has focused on children with learning disabilities. SI therapy has also been evaluated for treatment of children with developmental delays and Down syndrome. Tutoring of children with learning disabilities is a more traditional approach and, in randomized trials of SI therapy, tutoring is often provided to the comparison group. In contrast to SI therapy, which involves no presentation of academic material, tutoring involves individual sessions with a special education teacher who identifies weaknesses and provides exercises to improve reading, letter identification, phonetics, spelling, visual and auditory discrimination, vocabulary, and language concepts. A perceptual-motor approach, with activities such as dot-to-dot diagrams and tracing, may also be used to teach specific skills related to writing. SI therapy is usually provided by an occupational therapist, in which vestibular, proprioceptive, and tactile stimulation during activities are designed to elicit appropriate adaptive motor responses. This type of therapy does not involve tutoring, the more traditional approach to treatment of learning disabilities. Physical therapists work with the occupational therapists to utilize motor skills training methods that normally consist of adaptive physical education, movement education, and gymnastics. While these are important skills to work on, they feel that the sensory integrative approach is vital to treating SI disorders. The sensory integrative approach is guided by one important aspect, the child's motivation in selection of the activities. By allowing them to be actively involved, and explore activities that provide sensory experiences most beneficial to them, children become more mature and efficient at organizing sensory information. By providing treatment at an early age, sensory integration disorder may be managed successfully. The ultimate goal is for the individual to be better able to interact with his or her environment in a more successful and adaptive way. American Academy of Pediatrics (AAP) [2004]: The AAP Committee on Children with Disabilities has stated that the scientific legitimacy of SI therapy has not been established for children with motor disabilities. American Occupational Therapy Association (AOTA) [2004]: The AOTA Commission on Practice recognizes SI as one of several frames of reference that a therapist may use and apply in the process of occupational therapy for students who show deficits in SI that contribute to a significant, documented discrepancy in their skills within an educational program. The AOTA also states that some of its members do not advocate treatment with a SI framework, whereas other members are convinced that it offers benefits for certain children. Association for Science in Autism Treatment (ASAT) [2004]: A viewpoint published by ASAT states that, with regard to the diagnosis of SI disorder, there is no empirical support for the existence of the disorder independent of Ayres theoryspecific tests. The ASAT concludes that overwhelming scientific evidence indicates Physical and Occupational Therapy Oct 14 13

14 that SI therapy is ineffective and that practitioners of this therapy need to provide reliable evidence of its effectiveness instead of opinions and anecdotal reports. An assessment conducted by the National Initiative for Autism (UK) (2003) concluded: "Auditory integration therapy has also recently been subject to careful analysis, and again the results indicate that the effects are no greater than for placebo conditions. National Association of School Psychologists (NASP) [2002]: A study published by the NASP characterizes SI therapy as a modality that has not been found effective for children with learning disabilities, autism, or other developmental disabilities, despite an abundance of evidence from well-designed studies. The communiqué claims that, based on the available evidence, it is highly inappropriate to tell the public that SI therapy is a successful treatment to train practitioners in this type of therapy. Association for Comprehensive Neurotherapy (ACN) [2000]: The ACN claims that SI therapy is beneficial for some types of learning disabilities and is considered a useful component of a multidisciplinary approach to autism. Studies (2003) A Clinical Trial on Occupational Therapy to Treat Children Who Over or Under React to Their Environment has been completed, but no study results are posted at this time. The purpose of this study was to test children with SI dysfunction or Sensory Modulation Dysfunction (SMD). Diagnosis of SMD is based on physiological responses to specific stimuli, measures of behavioral/social/emotional symptoms, and studies of the resulting functional limitation and disability. Treatments involve direct biomedical and behavioral intervention to improve sensory processing, as well as adjustments to the home, school and community environment. This study will compare the effect of occupational therapy vs. alternative therapy on the reactivity and function of children who have SMD. A less extensive meta-analysis was conducted by Kaplan et al. (1993), who combined the results of two separate earlier studies of SI therapy for learning disabilities. Both of these studies met the criteria for detailed review (Polatajko et al., 1991; Wilson et al., 1992; Wilson et al., 1994). One study involved 29 children in Alberta, Canada, and the other involved 67 children in Ontario, Canada. Children who received SI therapy (n=49) were compared with thetutoring group from Alberta (n=15) and the perceptual motor treatment group from Ontario (n=31). Combining the studies increased the statistical power of the analysis; however, SI therapy was still not found to provide significant benefits. Although no differences between groups were found, all groups improved significantly over time, perhaps due to normal maturation (Kaplan et al., 1993). Although there have been a few randomized, controlled studies on sensory integration therapy that were blinded, they were very small (Uyanik et al. [2003], Bumin et al. [2001]). Various limitations in these studies were noted such as no assessment of cognitive, intellectual, or academic measures; no analysis of potential pre-treatment differences between groups; patients in non-treatment group reassigned to home-based treatment program during study; improvements in outcome measures not defined as positive or negative changes; and no follow/up after post treatment assessment. Physical and Occupational Therapy Oct 14 14

15 There was also some case controlled studies done (Paul et al. [2003], Salokorpi et al. [2002]). The limitations noted in these studies were small sample size with no follow-up after post-treatment assessment; a number of patients were excluded before treatment and excluded or lost to follow/up after treatment; and some of the patients underwent other forms of OT or PT in addition to study intervention. Additional larger randomized controlled trials comparing sensory integration to other forms of conventional therapy are necessary to determine if there are significant benefits from SI therapy. There are no Professional Society Position Statements that have determined that sensory integration therapy is the gold standard for individuals with sensory dysfunction. At this time, there is a lack of peer-reviewed, published medical literature to support the efficacy of this therapy. Scientific Rationale Initial Physical therapy and occupational therapy are medically prescribed treatments concerned with improving or restoring functions which have been impaired by illness or injury or, where function has been permanently lost or reduced by illness or injury, to improve the individual's ability to perform those tasks required for independent functioning. Physical therapy (PT) and occupational therapy (OT) are considered beneficial for a variety of acute and chronic conditions. Application of heat, cold, water, electricity, ultraviolet, sound, massage, and active, passive, and resistive exercise is intended to improve circulation, strengthen muscle, encourage return of motion, and train or retrain an individual to perform activities of daily living. The goal of physical and occupational therapy is the restoration of function or the reduction of disability. Definitions Homebound status: The patient is unable to safely leave his or her place of residence except with the aid of a supportive device, use of special transportation, assistance of another person, or a condition, which medically contraindicates leaving the home. Occupational therapy: Treatment for improving or restoring functions that have been impaired by illness or injury, or where function has been permanently lost or reduced by illness or injury, improving the patient s ability to perform those tasks required for independent functioning. Physical therapy: Corrective rehabilitation by the use of modalities of heat, cold, ultraviolet, water, electricity, sound, massage, and active, passive, and resistive exercise. Rehabilitation potential: The amount of improvement anticipated in a patient in relation to the extent and duration of the therapy provided. It includes consideration of previous functional status and the effects of the current condition or disease process. Significant and sustained improvement: The improvement in a patient s condition or functioning based on restorative potential. The improvement must be maintained and not immediately wane with the cessation of therapy. Physical Therapy Program Services The following services are generally included in a physical therapy program: Physical and Occupational Therapy Oct 14 15

16 Evaluation procedures, including testing of joint range of motion and mobility, skeletal muscle strength, posture, gait, limb length and circumference, activities of daily living, sensation and sensory perception, reflexes, muscle tone, sensorimotor response, and other types of skilled performance Massage, cold packs, ice, ice massage, hydrotherapy, hot pack, hydrocollator, infrared treatments, and paraffin, when the condition of the patient is such that the skills of a qualified provider are required or when provided as a prerequisite to skilled PT Therapeutic massage, when included as part of an overall PT treatment plan Ultrasound, short wave, microwave diathermy, ultraviolet, traction, transcutaneous nerve stimulation, iontophoresis, and alternate vascular compressor Mobility evaluation and training, when included as part of an overall PT treatment plan and when there is a reasonable expectation that the patient's ability to ambulate will improve Therapeutic exercises that require the skills of a qualified provider Range of motion (ROM) exercises, when related to restoration of a specific loss of function. ROM requires the skills of a qualified provider only when part of the active treatment of a specific condition that has resulted in loss or restriction of mobility Electrical stimulation (to control pain), when rendered by a certified physical therapist Debridement, when rendered by a certified physical therapist Occupational Therapy Program Services The types of services ordinarily provided in occupational therapy include all of the following: Evaluation of a patient s functional level Selection and teaching of task-oriented therapeutic activities designed to restore physical function Planning, implementing, and supervising individualized therapeutic activity programs as an integral part of an overall active treatment program for a patient with a diagnosed psychiatric illness Teaching compensatory techniques to improve the level of independence in the activities of daily living Designing, fabricating, and fitting of custom orthotic and self-help devices Review History December 1992 November 1995 October 1996 October 1998 March 1999 June 2002 June 2005 July 2006 March 2007 June 2007 April 2008 August 2008 National Medical Directors Advisory Group First review date Second review date Third review date Fourth review date Fifth review date National Medical Advisory Council review Removal of specialty requirement in policy statement Coding Updates Update no changes Under Not Medically Necessary: Changed statement from Symptoms generally associated with pregnancy to Pregnancy related musculoskeletal symptoms Added pregnancy related severe etc to indications Physical and Occupational Therapy Oct 14 16

17 February 2009 March 2009 July 2010 June 2011 March 2012 October 2012 March 2013 November 2013 February 2014 September 2014 October 2014 July 2015 Added Sensory and auditory integration therapies for the management of individuals with various communication, behavioral, emotional, and learning disorders, as not medically necessary. Codes reviewed. Removed infantile autism from the section that includes diagnoses for which OT is not medically necessary Added statement regarding Aquatic Therapy Update no revisions. Code updates. Medicare table added. Added section on severe mental illness, clarified maintenance therapy Clarified the need for a physician order to initiate PT and OT Update no revisions. Codes updated. MAC review - Added habilitative services coverage for January 2014 Added section on Occupational Therapy and updated sensory integration therapy Updated sensory and auditory integration therapy in Scientific Rationale Under documentation requirements, clarified that reevaluation should occur every three months Added to check for state specific guidelines regarding direct access Patient Education English 1. Medline Plus. Physical medicine and rehabilitation. Available at: Spanish 1. Medline Plus. Fisiatría y rehabilitación. Available at: References September Section On Complementary And Integrative Medicine and Council on Children with Disabilities. American Academy of Pediatrics. Sensory integration therapies for children with developmental and behavioral disorders. Pediatrics 2012;129; Devlin S, Healy O, Leader G, Hughes BM. Comparison of behavioral intervention and sensory-integration therapy in the treatment of challenging behavior. J Autism Dev Disord. 2011;41(10): Hodgetts S, Magill-Evans J, Misiaszek JE. Weighted Vests, Stereotyped Behaviors and Arousal in Children with Autism. J Autism Dev Disord Sep Lang R, O Reilly M, Healy O, et al. Sensory integration therapy for autism spectrum disorders: A systematic review. Research Autism Spect Dis. 2012(6): Stephenson J, Carter M. The use of weighted vests with children with autism spectrum disorders and other disabilities. J Autism Dev Disord Jan;39(1): Williames L.D. & Erdie-Lalena C.R. Complementary, Holistic, and Integrative Medicine: Sensory Integration. Pediatr. Rev. 2009;30;e91-e Wuang YP, Wang CC, Huang MH, et al. Prospective study of the effect of sensory integration, neurodevelopmental treatment, and perceptual-motor therapy on the Physical and Occupational Therapy Oct 14 17

18 sensorimotor performance in children with mild mental retardation. Am J Occup Ther 2009 Jul-Aug;63(4): Fey ME, Richard GJ, Geffner D, et al. Auditory processing disorder and auditory/language interventions: an evidence-based systematic review. Lang Speech Hear Serv Sch 2011; 42: McArthur, Genevieve M. Auditory processing disorders: can they be treated? Current Opinion in Neurology 2009;22(2): Moore DR, Ferguson MA, Edmondson-Jones M, et al. Nature of auditory processing disorder in children. Pediatrics 2010;126;e382-e390. References Update February Zimmer, M., Desch, L., Rosen, L. D., Bailey, M. L., Becker, D., Culbert, T. P. etal. (2012). Sensory integration therapies for children with developmental and behavioral disorders. Pediatrics, 129(6), 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; 65(1): Watling R, Koenig KP, Davies PL et al. Occupational therapy practice guidelines for children and adolescents with challenges in sensory processing and sensory integration. Bethesda, MD: American Occupational Therapy Association Press; Guideline summary [Website]: Accessed February 1, May-Benson,TA., Koomar,J.A. (2010) Systematic review of the research evidence examining the effectiveness of interventions using a sensory integrative approach for children. Am J Occup Ther. May-Jun;64(3): References Update March Greer N, Brasure M, Wilt TJ. Wheeled mobility (wheelchair) service delivery: scope of the evidence. Ann Intern Med 2012; 156: Hoenig H, Kortebein PK, Overview of geriatric rehabilitation: Program components and settings for rehabilitation. UpToDate October 11, Jenq G, Tinetti ME. The journey across the health care (dis)continuum for vulnerable patients: policies, pitfalls, and possibilities. JAMA 2012; 307:2157. References Update June Larun L, Malterud K. Exercise therapy for patients with chronic fatigue syndrome. Tidsskr Nor Laegeforen Feb 4;131(3):231-6 References Update February Krull KR. Overview of the treatment and prognosis of attention deficit hyperactivity disorder in children and adolescents. June 18, UpToDate. 2. McDonough-Means, Cohen MW. Rakel-Integrative Medicine, 2nd Edition. Chapter 11, Attention Deficit Disorder. 3. Weber W, Newmark S. Complementary and Alternative Medical Therapies for Attention-Deficit/Hyperactivity Disorder and Autism. Pediatric Clinics of North America - Volume 54, Issue 6 (December 2007). 4. Foy JM, Earls MF. A process for developing community consensus regarding the diagnosis and management of attention-deficit/hyperactivity disorder. Pediatrics, 2005 Jan; 115 (1): e Physical and Occupational Therapy Oct 14 18

19 5. HAYES Medical Technology Directory. Sensory Integration Therapy for Children with Learning Disabilities or Developmental Delays. Lansdale, PA: HAYES, Inc.; Winifred S. Hayes Dec. 6. American Occupational Therapy Association (AOTA). The role of OT in sensory integration is spotlighted on ABC s Centers for Medicare & Medicaid Services (CMS). Medicare Coverage Database Homepage searched for sensory and integration. Updated November 28, ClinicalTrials.gov. Occupational therapy to treat children who over or under react to their environment. Reviewed March Paul S, Sinen P, Johnson J, et al. The effects of a sensory motor activities protocol based on the theory of sensory integration on children diagnosed with preprimary impairments. Occup Ther Health Care. 2003;17(2): Uyanik M, Bumin G, Kayihan H. Comparison of different therapy approaches in children with Down syndrome. Pediatr Int. 2003;45(1): Salokorpi T, Rautio T, Kajantie E, et al. Is early occupational therapy in extremely preterm infants of benefit in the long run? Pediatr Rehabil. 2002;5(2): Hender K. Effectiveness of sensory integration therapy for attention deficit hyperactivity disorder (ADHD). Evidence Centre Critical Appraisal. Clayton, VIC: Centre for Clinical Effectiveness (CCE); Schweitzer JB, Cummins TK, Kant CA. Attention-deficit/hyperactivity disorder. Med Clin North Am. 2001;85 (3): Hender K. Effectiveness of sensory integration therapy for attention deficit hyperactivity disorder (ADHD). Series 2001: intervention. Clayton, Victoria, Australia: Centre for Clinical Effectiveness (Evidence Centre Critical Appraisal); 2001 Mar. 15. Bumin G, Kayihan H. Effectiveness of two different sensory-integration programmes for children with spastic diplegic cerebral palsy. Disabil Rehabil. 2001;23(9): Smith BH, Waschbusch DA, Willoughby MT, et al. The efficacy, safety, and practicality of treatments for adolescents with attention-deficit/hyperactivity disorder (ADHD). Clin Child Fam Psychol Rev. 2000;3 (4): Association for Comprehensive Neurotherapy (ACN). Sensory Integration Therapy. Latitudes. 2000;1(3&4). Available at: Clinical practice guideline: diagnosis and evaluation of the child with attentiondeficit/hyperactivity disorder. American Academy of Pediatrics. Pediatrics 105. (5): Kaplan BJ, Polatajko HJ, Wilson BN, et al. Reexamination of sensory integration treatment: a combination of two efficacy studies. J Learn Disabil. 1993;26 (5): References - Update June Sangster CA, Beninger C, Polatajko HJ, Mandich A. Cognitive strategy generation in children with developmental coordination disorder. Can J Occup Ther Apr;72(2): Warren RL, Wirtalla C. The relation between therapy intensity and outcomes of rehabilitation in skilled nursing facilities. Arch Phys Med Rehabil Mar;86(3): Yen JG, Wang RY, Chen HH, Hong CT. Effectiveness of modified constraintinduced movement therapy on upper limb function in stroke subjects. Acta Neurol Taiwan Mar;14(1): Physical and Occupational Therapy Oct 14 19

20 4. Eliasson AC, Krumlinde-sundholm L, Shaw K, Wang C. Effects of constraintinduced movement therapy in young children with hemiplegic cerebral palsy: an adapted model. Dev Med Child Neurol Apr;47(4): Ellis T, de Goede CJ, Feldman RG, et al. Efficacy of a physical therapy program in patients with Parkinson's disease: a randomized controlled trial. Arch Phys Med Rehabil Apr;86(4): Centers for Medicare and Medicaid Services. Carriers Manual Part 3. Chapter II Coverage and Limitations. Accessed May Suputtitada A, Suwanwela NC, Tumvitee S. et al. Effectiveness of constraintinduced movement therapy in chronic stroke patients. J Med Assoc Thai Dec;87(12): Dziedzic K, Hill J, Lewis M, et al. Effectiveness of manual therapy or pulsed shortwave diathermy in addition to advice and exercise for neck disorders: a pragmatic randomized controlled trial in physical therapy clinics. Arthritis Rheum Apr 15;53(2): Harris-Love MO, Shrader JA. Physiotherapy management of patients with HIVassociated Kaposi's sarcoma. Physiother Res Int. 2004;9(4): References - Initial 1. American Occupational Therapy Association, Inc. Standards of Practice for Occupational Therapy Internet: Accessed: May 9, Department of Health and Human Services, Health Care. Financing Agency, Medicare Guidelines Related to Physical Therapy. Important Notice General Purpose. Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether under the facts and circumstances of a particular case, the proposed procedure, drug, service or supply is medically necessary. The conclusion that a procedure, drug, service or supply is medically necessary does not constitute coverage. The member's contract defines which procedure, drug, service or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net s National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment, and services. In order to be eligible, all services must be medically necessary and otherwise defined in the member's benefits contract as described this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the member s benefits, nor is it intended to dictate to providers how to practice medicine. Policy Effective Date and Defined Terms. The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. * In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative. Physical and Occupational Therapy Oct 14 20