Cigna / ASH Medical Coverage Policies

Cigna / ASH Medical Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document may differ significantly from the standard benefit plans upon which these Cigna / ASH Medical Coverage Policies are based. In the event of a conflict, a customer’s benefit plan document always supersedes the information in the Cigna / ASH Medical Coverage Policy. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document.

Determinations in each specific instance may require consideration of:

1. the terms of the applicable benefit plan document in effect on the date of service
2. any applicable laws/regulations
3. any relevant collateral source materials including Cigna-ASH Medical Coverage Policies and
4. the specific facts of the particular situation

Cigna / ASH Medical Coverage Policies relate exclusively to the administration of health benefit plans. Cigna / ASH Medical Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines. Some information in these Coverage Policies may not apply to all benefit plans administered by Cigna. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make benefit determinations. References to standard benefit plan language and benefit determinations do not apply to those clients.

Coverage for sensory integration therapy (SIT), auditory integration therapy (AIT) or facilitated communication (FC) therapy varies across plans. Refer to the customer’s benefit plan document for coverage details. Note: This Medical Coverage Policy does not address sensory desensitization therapy.

GUIDELINES

Medically Necessary Ayres Sensory Integration Therapy®

is considered medically necessary for treatment of individuals with Autism Spectrum Disorder when ALL of the following have been met:

• The individual’s condition has the potential to improve or is improving in response to therapy, maximum improvement is yet to be attained; and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.
• The program is individualized, and there is documentation outlining quantifiable, attainable treatment goals.

Sensory and Auditory Integration Therapy - Facilitated Communication (CPG 149)

• Progress toward short and long term goals is documented to support continuation of treatment and goals are not yet met. Improvement is evidenced by successive objective measurements.
• Generalization and carryover of targeted skills into natural environment is occurring.
• The services are delivered by a qualified provider of therapy services (i.e., appropriately trained and licensed by the state to perform therapy services).
• Individual is actively participating in treatment sessions.
• Therapy occurs when the judgment, knowledge, and skills of a qualified provider of therapy services (as defined by the scope of practice for therapists in each state) are necessary to safely and effectively furnish a recognized therapy service due to the complexity and sophistication of the plan of care and the medical condition of the individual, with the goal of improvement of an impairment or functional limitation.

Experimental, Investigational, Unproven

Ayres Sensory Integration Therapy is considered experimental, investigational or unproven for any other indication.

All other forms of sensory integration therapy (SIT), auditory integration therapy (AIT) or facilitated communication (FC) therapy are each considered experimental, investigational or unproven for any indication.

Sensory Integration Therapy (SIT)

Sensory Integrative Techniques (SIT), also known as Sensory Integrative Therapy, are performed to enhance sensory processing and promote adaptive responses to environmental demands by changing underlying neurological processing through the use of activities that challenge a child to gradually engage in more challenging tasks and thus produce more complex and adaptive responses. Simply, SIT has been proposed as a method to improve the way the brain processes and organizes external stimuli, such as touch, movement, body awareness, sight and sound. The ultimate goal of SIT is to improve cognitive, behavioral, and social functioning of children (Hayes, 2017).

Auditory Integration Therapy (AIT)

Auditory integration therapy or training (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 via headphones to a program of specially 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 provided by a speech-pathologist or audiologist.

Facilitated Communication (FC)

Facilitated Communication (FC) is a method of providing assistance to a nonverbal person by typing out words using a typewriter, computer keyboard, or other communication device. FC involves supporting the individual's hand to make it easier for him or her to indicate the letters that are chosen sequentially to develop the communicative statement.

GENERAL BACKGROUND

Sensory Integration Therapy

SIT techniques 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. Sensory stimulation is provided in combination with muscle activities, theoretically in order to improve how the brain processes and organizes sensory information. The therapeutic techniques may include deep brushing, swings for vestibular input,

• textures
• bounce pads
• scooter boards
• weighted vests and other clothing
• ramps and generally increasing or decreasing sensory diet depending on the needs of the child (Shaw, 2002).

SIT has been proposed as a treatment of developmental disorders in patients with established dysfunction of sensory processing, e.g., children with autism, attention deficit hyperactivity disorder (ADHD), brain injuries, fetal alcohol syndrome, and neurotransmitter disease. Sensory integration therapy may be offered by occupational and physical therapists. 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 techniques are used to organize the sensory system by involvement of full body movements that provide vestibular, proprioceptive and tactile stimulation. As mentioned, brushes, swings, balls, and other specially designed therapeutic or recreational equipment are used to provide these stimuli. Proponents believe the goal of SIT is to improve the way the brain processes and organizes sensations, as opposed to teaching higher order skills themselves. 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 may be 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. Sensory integration techniques are generally associated with pediatric populations.

Advocates have proposed SIT as a treatment for developmental disorders in patients with established dysfunction of sensory processing, such as children with autism, attention deficit hyperactivity disorder (ADHD), brain injuries, fetal alcohol syndrome, and neurotransmitter disease. According to the American Academy of Pediatrics (AAP), (2012) "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. 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."

Additionally, 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, including autism spectrum disorders, attention-deficit/hyperactivity disorder, developmental coordination disorders, and childhood anxiety disorders. The therapeutic approach of sensory integration was originally developed by A. Jean Ayres, PhD, OTR, and is known as Ayres Sensory Integration® (AIS®).

Once the evaluation is complete, the therapist will design an intervention plan aimed at enhancing the child’s unique ability to utilize sensation. The fidelity principles of Ayres sensory integration include (Parham, et al., 2011):

• Children integrate sensory information from their bodies and the environment.
• Include visual, auditory, tactile, proprioceptive, and vestibular input.
• Individually tailored activities that challenge sensory processing and motor planning, encourage movement and organization of self in time and space, and utilize “just right” challenges.
• Incorporate clinical equipment in purposeful and playful activities to improve adaptive behavior.
• Implemented by trained therapy practitioners.
• Used only after an evaluation is completed and a need for such intervention is identified.

Auditory Integration Therapy

Auditory Integration Therapy (AIT) has been proposed for improving abnormal sound sensitivity in individuals with behavioral disorders, including autism spectrum disorders.

AIT aims to address the sensory problems which are said to cause discomfort and confusion in people with learning disabilities, including autism spectrum disorders. These hypersensitivities are believed to interfere with an individual’s attention, comprehension, and ability to learn. Thus, it has been proposed for improving abnormal sound sensitivity in these individuals with behavioral disorders, including autism spectrum disorders. Berard, whose method is the most widely studied, theorizes that auditory distortions may result in such behavioral disturbances as autism spectrum disorders, learning disabilities, depression, and aggressiveness. Berard suggests that AIT treats these distortions by exercising the middle ear muscles and auditory nervous system similar to physical therapy retraining muscles for orthopedic conditions. An audiogram, frequently the first step in the Berard method of AIT, is believed to help identify the presence of the auditory abnormalities and is used to monitor possible changes as a result of treatment.

Berard claims that following AIT, children's audiograms that previously had peaks and valleys, demonstrating areas of hyper- and hyposensitivity, are “flattened,” reflecting the elimination of auditory distortions and, subsequently, an improvement in behavioral abnormalities. According to Berard, optimal treatment consists of two half-hour sessions per day separated by a minimum of 3 hours, for 10 consecutive working days. A 2-day weekend interruption is acceptable. Despite current practice in the United States, Berard does not recommend follow-up sessions or any modifications to this treatment regimen. Results are evaluated by reviewing the audiogram obtained at the end of the 20 sessions and behavior changes at other post-treatment intervals.

Sensory and Auditory Integration Therapy - Facilitated Communication (CPG 149)

Facilitated Communication Facilitated communication bills itself as a way to allow individuals with autism, intellectual disability, or a condition like cerebral palsy to communicate by means of a “facilitator.” Facilitators provide pressure to the hand, wrist, or arm, guiding the individual to letters, words, or pictures—typically on a keyboard, smartphone, or tablet. Given it is a technique whereby individuals with disabilities and communication impairments allegedly select letters by typing on a keyboard while receiving physical support, emotional encouragement, and other communication supports from facilitators, the validity of FC stands or falls on the question of who is authoring the typed messages- -the individual with a disability or the facilitator. Thus, FC has been at the center of debate because several scientific studies have suggested that facilitators may unintentionally influence the communication, perhaps to the extent of actually selecting the words themselves.