Sensory integration and insurance coverage

My tongue-in-cheek commentary on fidelity in sensory integration and coverage for geriatric SI has generated a lot of email questions: a lot of people wanted to know the policies of most insurance companies. Obviously the insurance company I was poking fun at was covering something that they are calling sensory integration but I am not convinced that their definition matches that of many other people.

Here is a summary of the sensory integration policies of the largest health insurance companies in the US:

United Healthcare policy

Sensory integration therapy is unproven for the treatment of any condition... The available studies of sensory integration therapy are weak and inconclusive and derived primarily from poorly controlled trials with methodological flaws. These trials fail to demonstrate that sensory integration therapy provides long-term improvement in neurological development and behavioral development. There is no reliable data from well designed clinical studies that indicate that sensory integration therapy improves clinical outcomes in patient with cerebrovascular accidents, speech disturbances, gait abnormalities, or other medical conditions. Further and better designed clinical trials of sensory integration therapy are necessary in order to establish their clinical usefulness.

Cigna policy

Sensory integration therapy is specifically excluded under many health benefit plans. In addition, many benefit plans specifically exclude behavioral training and services, training, educational therapy or other nonmedical ancillary services for learning disabilities, developmental delays, autism or mental retardation. Cigna does not cover sensory integration therapy (SIT), auditory integration therapy (AIT) or facilitated communication (FC) therapy for any indication because they are considered experimental, investigational or unproven.

Aetna policy

Aetna considers sensory and auditory integration therapies experimental and investigational for the management of persons with various communication, behavioral, emotional, and learning disorders and for all other indications. The effectiveness of these therapies is unproven.

Blue Cross Blue Shield policy

(there are many BCBS plans - this is representational)
Sensory Integration Therapy is considered investigational. BCBSNC does not provide coverage for investigational services or procedures... A recent literature search found no new clinical trials that would change the policy statement. Currently there is insufficient evidence that sensory integration therapy is effective. A lack of well-designed clinical trials prevents conclusions that this treatment improves health outcomes.

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For reference purposes, here is a link to a letter written by AOTA in response to BCBS of North Dakota's policy. I have some mixed feelings about the letter. On one hand I appreciate the advocacy but on the other hand I feel like it is not acknowledging the limitations of the current research. Specifically in this example, AOTA referenced two studies that purport to demonstrate effectiveness of SI. In fact some of the above linked insurance companies had already l0oked at those articles and suggested that they still lacked appropriate statistical power and had sample sizes that were too small.

A logical question is: Why would AOTA advocate so strongly for something that is still (apparently) not fully supported by research? If over time, independent people (not just insurance companies, but projects like the National Standard's Report or the NYS Early Intervention Clinical Practice Guidelines) have stated that an approach is investigational then what causes a professional association to advocate so strongly?

Arguably, insurance companies or even governmental agencies that have to pay for services may have an inherent interest in limiting coverage or limiting approval to very restricted intervention techniques. Still, they have to stand against public scrutiny of their positions. It is logical to assume that if public scrutiny works then there must be SOME VALIDITY to the fact that sensory integration should be considered investigational.

If there is even partial validity to all of these policies, then why does a professional association continue to advocate a different position instead of ACCEPTING the designation of sensory integration as 'investigational.' This is all fodder for conjecture. Is it possible that AOTA is experiencing sunk-cost bias?

If we define 'AOTA' not as a bricks and mortar building in Bethesda but rather as the collective consciousness of a whole lot of dues-paying members - is it possible that we have invested too much into this concept OR that we are invested so that we are unable to place ourselves on a different path to define, refine, and advance the intervention strategy in the best possible way?

This is an important question because as we struggle as a profession with the issue of fidelity in research are we sure that we are efficiently and effectively allocating our efforts? As sure as this question will generate hate mail, I will be equally sure that the hate mail itself will be evidence of the need for occupational therapists to examine this more closely.

Comments

Barbara TherExtras said…
I scratch my head over the whining of OTs regarding lack of insurance coverage for anything 'sensory'. For heaven's sake! Use techniques that are effective for a particular child to bring them to functional tasks - bill for 'function' or ADL. Really.
10:49 PM
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