659 Form

1

Medical Policy Sensory Integration Therapy and Auditory Integration Therapy Table of Contents
• Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 659 BCBSA Reference Number: 8.03.13 (For Plan internal use only) Related Policies

Cognitive Rehabilitation, #660 Policy
Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

Sensory integration therapy and auditory integration therapy are considered INVESTIGATIONAL.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) This is not a covered service. Commercial PPO and Indemnity This is not a covered service.

CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

2

The following CPT code is considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity:

CPT Codes CPT codes: Code Description 97533 Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes

Description The goal of sensory integration therapy is to improve how 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. 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.

Auditory integration therapy (also known as auditory integration training, auditory enhancement training, audio-psycho-phonology) involves having individuals listen to music modified to remove frequencies to which they are hypersensitive, with the goal of gradually increasing exposure to sensitive frequencies. Although several methods of auditory integration therapy have been developed, the most widely described is the Berard method, which involves 2 half-hour sessions per day separated by at least 3 hours, over 10 consecutive days, during which patients listen to recordings. Auditory integration therapy has been proposed for individuals with a range of developmental and behavioral disorders, including learning disabilities, autism spectrum disorder, pervasive developmental disorder, and attention- deficit/hyperactivity disorder. Other methods include the Tomatis method, which involves listening to electronically modified music and speech, and Samonas Sound Therapy, which involves listening to filtered music, voices, and nature sounds.1,

Summary Sensory integration therapy has been proposed as a treatment of developmental disorders in individuals with established dysfunction of sensory processing, particularly autism spectrum disorder. Sensory integration therapy may be offered by occupational and physical therapists who are certified in sensory integration therapy. Auditory integration therapy uses gradual exposure to certain types of sounds to improve communication in a variety of developmental disorders, particularly autism. Summary of Evidence For individuals who have developmental disorders who receive sensory integration therapy, the evidence includes systematic reviews of randomized controlled trials (RCTs) and case series. Relevant outcomes are functional outcomes and quality of life. Due to the individualized approach to sensory integration therapy and the large variations in patients’ disorders, large multicenter RCTs are needed to evaluate the efficacy of this intervention. The most direct evidence on sensory integration therapy outcomes derives from several RCTs. Although some of these trials demonstrated improvements for subsets of outcomes measured, they had small sample sizes, heterogeneous patient populations, and variable outcome measures. A RCT of 138 children ages 4 to 11 years published in 2022 found that sensory integration therapy for children with autism and sensory processing difficulties did not demonstrate clinical benefit above standard care. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. For individuals who have developmental disorders who receive auditory integration therapy, the evidence includes systematic reviews of RCTs. Relevant outcomes are functional outcomes and quality of life. For auditory integration therapy, the largest body of literature relates to its use in autism spectrum disorder. Several systematic reviews of auditory integration therapy in the treatment of autism have found limited

3

evidence to support its use. No comparative studies identified evaluated use of auditory integration therapy for other conditions. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Policy History Date Action 4/2026 Policy updated with literature review through January 13, 2026; references added. Policy statement unchanged. 5/2025 Annual policy review. Summary and references updated. Policy statements unchanged. 5/2024 Annual policy review. Policy updated with literature review through February 22, 2024; no references added. Policy statement unchanged. 5/2023 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 4/2022 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 4/2021 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 1/2021 Medicare information removed. See MP #132 Medicare Advantage Management for local coverage determination and national coverage determination reference.
5/2020 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 4/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 4/2016 Annual policy review. New references added. 4/2015 Annual policy review. Policy statement expanded to include investigational statement for auditory integration therapy. Title changed to reflect inclusion of auditory integration therapy. Effective 4/1/2015 11/2011- 4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates. No changes to policy statements.
1/2012 Reviewed - Medical Policy Group - Neurology and Neurosurgery. No changes to policy statements. 5/2011 Reviewed - Medical Policy Group - Pediatrics and Endocrinology. No changes to policy statements. 2/2011 Reviewed - Medical Policy Group - Psychiatry and Ophthalmology. No changes to policy statements. 1/2011 Reviewed - Medical Policy Group - Neurology and Neurosurgery. No changes to policy statements. 5/2010 Reviewed - Medical Policy Group - Pediatrics and Endocrinology. No changes to policy statements. 2/2010 Reviewed - Medical Policy Group - Psychiatry and Ophthalmology. No changes to policy statements. 1/2010 Reviewed - Medical Policy Group - Neurology and Neurosurgery. No changes to policy statements. 1/2010 Annual policy review. No changes to policy statements. 5/2009 Reviewed - Medical Policy Group - Pediatrics and Endocrinology. No changes to policy statements. 2/2009 Reviewed - Medical Policy Group - Psychiatry and Ophthalmology. No changes to policy statements. 1/2009 Reviewed - Medical Policy Group - Neurology and Neurosurgery. No changes to policy statements. 5/2008 Reviewed - Medical Policy Group - Pediatrics and Endocrinology. No changes to policy statements. 5/2008 Annual policy review. No changes to policy statements.

4

2/2008 Reviewed - Medical Policy Group - Psychiatry and Ophthalmology. No changes to policy statements. 1/2008 Reviewed - Medical Policy Group - Neurology and Neurosurgery. No changes to policy statements. 6/2007 Annual policy review. No changes to policy statements. 5/2007 Reviewed - Medical Policy Group - Pediatrics and Endocrinology. No changes to policy statements. 4/2007 Annual policy review. No changes to policy statements.
2/2007 Reviewed - Medical Policy Group - Psychiatry and Ophthalmology. No changes to policy statements. 1/2007 Reviewed - Medical Policy Group - Neurology and Neurosurgery. No changes to policy statements. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

1. Sinha Y, Silove N, Hayen A, et al. Auditory integration training and other sound therapies for autism spectrum disorders (ASD). Cochrane Database Syst Rev. Dec 07 2011; 2011(12): CD003681. PMID 22161380
2. Schaaf RC, Burke JP, Cohn E, et al. State of measurement in occupational therapy using sensory integration. Am J Occup Ther. 2014; 68(5): e149-53. PMID 25184475
3. Mailloux Z, May-Benson TA, Summers CA, et al. Goal attainment scaling as a measure of meaningful outcomes for children with sensory integration disorders. Am J Occup Ther. 2007; 61(2): 254-9. PMID 17436848
4. Parham LD, Cohn ES, Spitzer S, et al. Fidelity in sensory integration intervention research. Am J Occup Ther. 2007; 61(2): 216-27. PMID 17436844
5. Weitlauf AS, Sathe N, McPheeters ML, et al. Interventions Targeting Sensory Challenges in Autism Spectrum Disorder: A Systematic Review. Pediatrics. Jun 2017; 139(6). PMID 28562287
6. Case-Smith J, Weaver LL, Fristad MA. A systematic review of sensory processing interventions for children with autism spectrum disorders. Autism. Feb 2015; 19(2): 133-48. PMID 24477447
7. Camino-Alarcón J, Robles-Bello MA, Valencia-Naranjo N, et al. A Systematic Review of Treatment for Children with Autism Spectrum Disorder: The Sensory Processing and Sensory Integration Approach. Children (Basel). Oct 09 2024; 11(10). PMID 39457187
8. May-Benson TA, Koomar JA. Systematic review of the research evidence examining the effectiveness of interventions using a sensory integrative approach for children. Am J Occup Ther. 2010; 64(3): 403-14. PMID 20608272
9. Randell E, Wright M, Milosevic S, et al. Sensory integration therapy for children with autism and sensory processing difficulties: the SenITA RCT. Health Technol Assess. Jun 2022; 26(29): 1-140. PMID 35766242
10. Kaplan Kılıç B, Bumin G, Öğütlü H, et al. Comprehensive Effects of Occupational Therapy Using Ayres Sensory Integration® in Children With ADHD: A Randomized Controlled Trial. Am J Occup Ther. Jan 01 2026; 80(1). PMID 41343283
11. Corbett BA, Shickman K, Ferrer E. Brief report: the effects of Tomatis sound therapy on language in children with autism. J Autism Dev Disord. Mar 2008; 38(3): 562-6. PMID 17610057
12. Mudford OC, Cross BA, Breen S, et al. Auditory integration training for children with autism: no behavioral benefits detected. Am J Ment Retard. Mar 2000; 105(2): 118-29. PMID 10755175
13. Porges SW, Bazhenova OV, Bal E, et al. Reducing auditory hypersensitivities in autistic spectrum disorder: preliminary findings evaluating the listening project protocol. Front Pediatr. 2014; 2: 80. PMID 25136545

5

14. Zimmer M, Desch L, Rosen LD, et al. Sensory integration therapies for children with developmental and behavioral disorders. Pediatrics. Jun 2012; 129(6): 1186-9. PMID 22641765
15. Hyman SL, Levy SE, Myers SM, et al. Identification, Evaluation, and Management of Children With Autism Spectrum Disorder. Pediatrics. Jan 2020; 145(1). PMID 31843864
16. Sensory Integration Approaches for Children and Youth in Occupational Therapy Practice. Am J Occup Ther. Nov 01 2023; 77(Suppl 3). PMID 38175825
17. Occupational Therapy for Children and Youth Using Sensory Integration Theory and Methods in School-Based Practice. Am J Occup Ther. 2015; 69 Suppl 3: 6913410040p1-6913410040p20. PMID 26713950
18. 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; 2011.
19. American Speech-Language-Hearing Association, Working Group in AIT. Auditory Integration Training [Technical Report:]. 2004; https://www.asha.org/policy/ps2004-00218/. Accessed January 9, 2026.