Does not apply to Federal Employee Program (FEP).
Sensory integration therapy has been proposed as a treatment of developmental disorders in individuals with established dysfunction of sensory processing, such as children with autism, attention-deficit/hyperactivity disorder, brain injuries, fetal alcohol syndrome and neurotransmitter disease. The goal of sensory integration is to improve the way the brain processes and adapts to sensory information as opposed to teaching specific skills. Therapy usually involves activities that provide vestibular, proprioceptive and tactile stimuli which are selected to match specific sensory processing deficits of the child.
Auditory integration therapy uses gradual exposure to sounds to which individuals are sensitive. Auditory integration training has been proposed for individuals with a range of developmental and behavioral disorders, including learning disabilities, autism spectrum disorders, pervasive developmental disorder, attention deficit and hyperactivity disorder.
Sensory and auditory integration therapies are considered investigational. (Except when Tennessee State Mandate applies. See Applicable Tennessee State Mandate Requirements below.)
APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS
The Tennessee state law quoted below applies to individual policies, fully insured accounts, and self-funded accounts that are not governed by ERISA (i.e. governmental plans and church plans). Please keep in mind that it can be very difficult to determine if such a Plan is a governmental plan, (for example some utilities are governmental plans), or a church plan (for example some hospital plans are church plans.) This mandate applies to such accounts that are delivered, issued for delivery, amended or renewed on or after January 1, 2007. This mandate does not apply to self-funded accounts that are governed by ERISA unless an ERISA governed self-funded account's plan language, Explanation of Coverage (EOC), or Summary Plan Description provides coverage for these particular disorders. An ERISA governed self-funded plan's language will govern application of this policy to a plan. In addition, other federal laws will preempt this provision. In particular, the Federal Employees Program is governed by federal law and contains a provision that preempts claims and benefits similar to ERISA. The provisions of this mandate concern autism spectrum disorders and are applicable to individuals of less than twelve (12) years of age.
Tennessee Code Annotated, Title 56, Chapter 7, Part 23, was amended by adding the following languages as a new section to be appropriately designated:
As used in this section, "autism spectrum disorders" means neurological disorders, usually appearing in the first three (3) years of a person's life that affect normal brain functions and are typically manifested by impairments in communication and social interaction, as well as restrictive, repetitive, and stereotyped behaviors.
A contract or policy of an insurer that provides benefits for neurological disorders, whether under an individual or group health insurance policy providing coverage on an expense-incurred basis, an individual or group service contract issued by a health maintenance organization, a self-insured group arrangement to the extent not preempted by federal law or a managed health care delivery entity of any type or description shall provide benefits and coverage for treatment of autism spectrum disorders that are at least as comprehensive as those provided for other neurological disorders. These benefits and coverage for treatment shall be provided to any person less than twelve (12) years of age.
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits, or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
Does not apply to Federal Employee Program (FEP).
Small randomized trials found that sensory integration therapy demonstrated improvements for subsets of outcomes measured. Limitations to these trials include small sample size, heterogeneous patient populations and variable outcome measures. The evidence is insufficient to determine the effects of the technology on health outcomes. Several systematic reviews of auditory integration therapy found limited evidence to support its use. No comparative studies were identified that evaluated its use for other conditions.
Agency for Healthcare Research and Quality. (2011). Comparative Effectiveness Review Number 26. Therapies for children with autism spectrum disorders. Retrieved December 10, 2012 from www.ahrq.gov.
Agency for Healthcare Research and Quality. (2017). Comparative Effectiveness Review Number 186. Interventions targeting sensory challenges in children with autism spectrum disorder – an update. Retrieved October 20, 2017 from www.ahrq.gov.
American Academy of Child and Adolescent Psychiatry (2014, February)Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder. Retrieved November 4, 2016 from National Guideline Clearinghouse. (NGC: 010489).
American Academy of Pediatrics. (2012, May). Sensory integration therapies for children with developmental and behavioral disorders. Retrieved December 10, 2012 from http://pediatrics.aappublications.org.
BlueCross BlueShield Association. Medical Policy Reference Manual. (3:2017). Sensory integration therapy and auditory integration therapy. Retrieved October 20, 2017 from BlueWeb. (21 articles and/or guidelines reviewed)
Case-Smith, J., Weaver, L., & Fristad, M. (2015). A systematic review of sensory processing interventions for children with autism spectrum disorders. Autism, 19 (2), 133-148. Abstract retrieved October 20, 2017 from PubMed database.
National Institute for Health and Care Excellence. (2013). Autism in under 19s: support and management. Retrieved January 4, 2016 from www.nice.org.uk.
Schaaf, R., Benevides, T., Mailloux, Z., Faller, P., Hunt, J., van Hooydonk, E., et al. (2014). An intervention for sensory difficulties in children with autism: a randomized trial. Journal of Autism and Developmental Disorders, 44, 1493-1506. (Level 2 evidence)
Tennessee Code: Title 56 Insurance: Chapter 7 policies and Policyholders: Part 23 Mandated Insurer or Plan Coverage: 56-7-2367. Autism spectrum disorders. Retrieved October 20, 2017 from http://www.lexisnexis.com/hottopics/tncode/.
Watling, R. & Hauer, S. (2015). Effectiveness of Ayres sensory integration® and sensory-based interventions for people with autism spectrum disorder: a systematic review. The American Journal of Occupational Therapy, 69 (5). DOI: 10.5014/ajot.2015.018051. Abstract retrieved October 20, 2017 from PubMed database.
Winifred S. Hayes, Inc. Medical Technology Directory. (2014, March; last update search February 2017). Sensory integration therapy for non-autistic children. Retrieved October 20, 2017 from www.Hayesinc.com/subscribers. (78 articles and/or guidelines reviewed)
MOST RECENT REVIEW DATE: 11/9/2017
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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