Field report: Fidelity problems persist with 'sensory integration'

Consider this as Part II of Sensory integration: More evidence that OTs have lost control of the narrative. A major HMO in my region just published a clinical practice guideline update on sensory integration, which I will re-publish in full below. However, if you want to understand the fidelity problem, I think the graphic to the left says it all.

Sensory Integration Therapy

Implemented By: Chief Medical Officer, Health Care Services

Policy No.: M110207082

Effective Date: May 1, 2011

Location/Type: MRM/EXT

Revised Date: May 1, 2012

Signature: (Signed copy on file)

Reviewed Date:

To provide clinical coverage guidelines for sensory integration therapy for Independent Health plan members.

Responsible Departments: Medical Resource Management

Applicable Vendor: N/A

Sensory 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.

Corporate Medical Guideline:
Sensory 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 Guideline:
Sensory 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.


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
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)
Encompass 65 (HMO-POS)
Family Health Plus
Passport Plan Select
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.

Reviewed/Revised Dates:


Revised: 05/01/2012

Caution:Independent Health updates its corporate policies frequently. Please reference the Internet for the most current version.


Barbara said…
I might need some help with this, Chris. While your title is certainly apt and understandable, I need help interpreting insurance-gobledygook. Is SI therapy covered, or not?

I am with you on the lack of evidence of effectiveness for therapy provided under the moniker of SI-anything.
It is covered - but for Medicare Part C! Those are Medicare Advantage plans - for senior citizens. That is why I said there are fidelity problems!

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