Implemented By: Chief Medical Officer, Health Care Services
Policy No.: M110207082
Effective Date: May 1, 2011
Revised Date: May 1, 2012
Signature: (Signed copy on file)
Reviewed Date PurposeTo provide clinical coverage guidelines for sensory integration therapy for Independent Health plan members.
Responsible Departments: Medical Resource Management
Applicable Vendor: N/A
DefinitionsSensory integration therapy: sensory integrative techniques are performed to enhance sensory processing and promote adaptive responses to environmental demands. These treatments are performed when a deficit in processing input from one of the sensory systems (e.g., vestibular, proprioceptive, tactile, visual or auditory) decreases an individual’s ability to make adaptive sensory, motor and behavioral responses to environmental demands. Individuals in need of sensory integrative treatments demonstrate a variety of problems, including sensory defensiveness, over-reactivity to environmental stimuli, attention difficulties, and behavioral problems.
PolicyCorporate Medical GuidelineSensory integration therapy is a covered benefit only for Medicare Advantage members. Insufficient evidence exists in the form of a well-designed, large-population, prospective, randomized, controlled trials to draw definitive conclusions regarding the accuracy of sensory integration therapy and the impact of sensory integration therapy testing to determine if such tests result in improved health outcomes.
Medicare Advantage Medical GuidelineSensory integration may be considered medically necessary for acquired sensory defects resulting from ¨ Head trauma;
¨ Illness; or
¨ Acute neurological events including cerebrovascular accidents.
Sensory integration is not appropriate for Medicare members with progressive neurological conditions without potential for functional adaptation.
Therapy is not considered a cure for sensory integrative impairments, but is used to facilitate the development of the nervous system’s ability to process sensory input differently.
References NGS LCD for Sensory Integration Therapy, L26884,01/01/10
Sensory Based Treatments for Autism Spectrum Disorders, Hayes Inc. Medical Directory 5/9/2011
Sensory Stimulation for Patients in a Persistent Vegetative State (PVS), Hayes Inc. Medical Directory 1/13/2012
Evidence based review of interventions for autism used in or of relevance to occupational therapy, Case-Smith J. Arbesman, 2008
This policy applies to X All Products*
FlexFit Select Child Health Plus Healthy New York Easy Access Healthy New York Select Empower iDirect Encompass Independent Health’s Medicare Family Choice (HMO-SNP) Encompass Plus Medicare Encompass (HMO) Encompass I2 Medicare Encompass (HMO-POS) Encompass Plus I2 Medicare Passport (PPO) Encompass 65 (HMO) MediSource Encompass 65 (HMO-POS) NYSHIP Evolve Passport Family Health Plus Passport Plan Select FEHB Traditional FlexFit Self-Funded (See Grids)*
*In the event of any conflict between this policy and the summary plan description (SPD) of a self-funded plan, the SPD shall supersede the policy.