CurrentAetnaPolicy 0151

Hippotherapy (Equine Therapy) — Clinical Policy Bulletin

Aetna Clinical Policy Bulletin on the use of hippotherapy (therapeutic horseback riding/equine-facilitated therapy) describing coverage stance, indications considered experimental/investigational, coding notes, and background evidence relevant to providers and payers.

Policy Summary

PayerAetna

PolicyHippotherapy (Equine Therapy) — Clinical Policy Bulletin

Policy CodePolicy 0151

Change TypeNo material changes noted

Effective DateN/A

Next Review DateN/A

Key ActionDo not bill HCPCS S8940 for the listed indications; ensure coding aligns with plan-specific coverage and documentation if requesting authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

S8940HCPCS not covered

>=1Aetna-listed excluded indications

04/06/2023Last review

03/31/1997Effective date (original)

MultipleSmall/low-quality studies

76/84

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CP children improved (pooled)

Coverage Determinations

inv-01: Experimental and Investigational — Hippotherapy coverage stance

Covered when ALL of the following are met:

Experimental and investigational indications: The use of hippotherapy is considered experimental and investigational for the treatment of the listed indications and all other indications because effectiveness has not been established.

Listed indications include Alzheimer's disease; anxiety; attention deficit and/or hyperactivity disorder; autism; behavioral and psychiatric disorders (including aggressive violent behavior, psychotic disorders and eating disorders); cerebral palsy or other motor dysfunctions (eg, arthritis, balance deficits, children with psychomotor impairment, head injury, multiple sclerosis, spinal cord injury, and stroke); childhood obesity; chronic pain (including low back pain); dementia; developmental delays; Down's syndrome; idiopathic scoliosis; post-traumatic stress disorder; rehabilitation of cancer survivors; sexual abuse and emotional stress; substance abuse disorder; and others.

inv-02: Evidence synthesis — potential benefit but low-certainty (study inclusion and outcomes summary)

Evidence summaries report some positive findings but emphasize limitations (small samples, heterogeneity, and low or very low certainty):

Systematic review/meta-analysis positive effects: Some systematic reviews and meta-analyses (for example, De Guindos‑Sanchez et al 2020 and Whalen & Case‑Smith 2012) reported favorable effects of hippotherapy on gross motor function and postural control in children with cerebral palsy, with standardized mean differences favoring HPT and findings that 45‑minute sessions once weekly for 8–10 weeks produced significant effects in selected studies.

These reviews note potential benefit but call for larger RCTs with specified protocols due to limited evidence (see chunks 35 and 24).

Contradictory/low‑quality evidence: Other systematic reviews (eg, de Assis et al 2022) found that physical therapy plus hippotherapy produced similar effects to physical therapy alone and rated the level of evidence as very low, with high risk of bias and small sample sizes, indicating uncertainty about added benefit of hippotherapy over standard PT.

See chunk 37 for pooled analyses and GRADE assessment.

Positive small studies/pilot data: Multiple small trials and pilot studies across populations (children with CP, ADHD, PTSD, MS, acquired brain injury and others) reported improvements in balance, postural control, gait parameters, motor function, and some symptom scales; however these are preliminary and limited by study design, small n, and heterogeneity.

Summaries and examples found in chunks 23, 55, 57, 58, and 65.

inv-03: Evidence-based considerations (no formal coverage criteria provided) — summaries and interpretation

Interpretation and operational considerations (no formal coverage criteria provided):

General evidence summary: Across indications the evidence is preliminary: many studies have small sample sizes, heterogeneous or ill‑defined interventions (hippotherapy, therapeutic riding, equine‑assisted activities, and simulators), short follow‑up, and methodological limitations; while some pilot studies suggest symptomatic or functional improvements, systematic reviews repeatedly call for larger, better‑designed RCTs and clear, standardized treatment protocols.

References include mapping reviews and condition‑specific systematic reviews that emphasize gaps in foundational work and the need for replication (chunks 70, 35, 37, 68).

The use of hippotherapy (equine therapy) is considered experimental and investigational (not covered) for the indications listed in this bulletin and for all other indications because effectiveness has not been established. Listed conditions include: Alzheimer’s disease; anxiety; attention deficit/hyperactivity disorder; autism; behavioral and psychiatric disorders; cerebral palsy and other motor dysfunctions; childhood obesity; chronic pain; dementia; developmental delays; Down’s syndrome; idiopathic scoliosis; post‑traumatic stress disorder; rehabilitation of cancer survivors; sexual abuse and emotional stress; substance abuse disorder; and others. Providers should note that HCPCS code S8940 and the ICD‑10 codes enumerated in the policy are identified as not covered when billed for these indications.

Clinical reviews and tertiary sources (e.g., UpToDate) list hippotherapy among interventions supported only by weak or low‑quality evidence and characterize it as an intervention for which routine recommendation is not justified pending stronger comparative data.

Systematic assessments of equine‑related treatments for mental disorders concluded that peer‑reviewed studies were compromised by multiple threats to validity, failed to show consistent benefit over the passage of time, and do not currently justify offering these services to the public.

For adults with acquired brain injury, pooled data from available controlled studies did not demonstrate statistically significant short‑term improvements in balance or gait versus control; long‑term functional benefits remain unproven due to limited follow‑up and small, heterogeneous trials.

Across populations and study types, the evidence base is limited by methodological weaknesses including small sample sizes, lack of control groups in some studies, heterogeneous intervention protocols (duration, frequency, use of real versus simulated horses), short follow‑up, and variable outcome measures, which together reduce confidence in reported effects.

In dementia trials of animal‑assisted therapy, reviewers noted no reported data on safety or effects on the animals; this gap limits interpretation of overall benefits and risks for patients and animals.

This Clinical Policy Bulletin provides a general description of plan benefits and does not constitute a contract. Coverage determinations remain subject to the member’s plan provisions and administrative rules.

Because the current evidence does not establish efficacy, hippotherapy is considered not established as effective for the conditions listed in this bulletin and therefore is designated as experimental/investigational for those indications.

Some comparative analyses report that adding hippotherapy to conventional physical therapy produced similar effects to physical therapy alone and rated the certainty of evidence as very low; where no added benefit is demonstrated, hippotherapy cannot be considered clearly superior to standard PT.

Studies of equine‑related treatments for mental disorders were frequently small and methodologically flawed, leaving conclusions about efficacy vulnerable to bias and limiting their clinical applicability.

A pooled analysis of controlled studies in adults with acquired brain injury found no statistically significant short‑term improvements in balance (SMD 0.24, 95% CI −0.05 to 0.54) or gait (SMD −0.04, 95% CI −0.79 to 0.72) immediately after intervention compared with control.

Reviews of hippotherapy in people with Down’s syndrome concluded there is no strong evidence supporting improvement in gross motor function and called for larger, higher‑quality studies to verify any effect.

Billing and Coding

HCPCS codes not covered for indications listedHCPCSNot Covered

S8940

Equestrian / hippotherapy, per session

ICD-10 codes not covered for indications listed (partial list)ICD-10Not Covered

A88.1	Epidemic vertigo
E66.8	Other obesity [Childhood obesity]
E66.9	Obesity, unspecified [Childhood obesity]
F01.50 - F99	Mental and behavioral disorders
F50.00 - F50.9	Eating disorders
G20	Parkinson's disease
G30.0 - G30.9	Alzheimer's disease
G35	Multiple sclerosis
G71.00 - G71.9	Primary disorders of muscles
G80.0 - G80.9	Cerebral palsy

1–10 of 33

1/4

BMI pediatric threshold — Z68.54

ICD-10 codeZ68.54

DescriptionBody mass index (BMI) pediatric, greater than or equal to 95th percentile for age

Context in policyListed among ICD-10 codes not covered for the indications in this Clinical Policy Bulletin (childhood obesity).

Provider Responsibilities, Authorization & Documentation

Prior Authorization

Prior Authorization — protocol & clinical justification

Prior authorization — protocol and clinical justification: When study protocols or clinic-specific treatment plans are used to support medical necessity, prior authorization may be appropriate to document the protocol (session frequency, duration, targeted outcomes) and clinical justification. Provide details of the intervention protocol (e.g., 45‑minute sessions once weekly for 8–10 weeks, or other trial-specific dosing), the treating clinician’s qualifications, and rationale linking the therapy to the member’s condition and functional goals.

Document protocol details: session duration, frequency, total number of sessions
Attach study protocol or treatment plan when applicable
Provide clinician credentials and scope of practice

Note

Prior authorization — not specified in excerpts

Prior authorization not specified in excerpt: Many source excerpts do not state an explicit prior authorization requirement. In such cases, providers should verify plan-level benefit documents or member-specific benefit coverage to determine whether prior authorization is required.

Definitions & Key Terms

Hippotherapy is the passive use of the horse’s physical movements, delivered under the supervision of a therapist who is knowledgeable about equine movement and therapeutic techniques. The intervention is intended to influence neuromotor function, posture, balance and gait, and has been applied most often in children with cerebral palsy and in other populations as an adjunctive therapy; however, definitions and protocols vary across studies and settings.

Definition — Hippotherapy (passive use of horse movement under therapist supervision)

TermHippotherapy

DefinitionThe passive use of the physical movements of the horse in the treatment of patients with neurological or other disabilities, typically performed under the direct supervision of a physical or occupational therapist who is horse-knowledgeable.

Typical deliveryHorse led at walking or trotting pace with therapist and assistants present to position and stabilize the patient; therapist may place patient in varied positions on the horse.

Definition — Level 2a evidence (fair-quality RCTs as used in cited systematic review)

Clinical Evidence & Background

Descriptions of hippotherapy in the literature emphasize equine movement as the core therapeutic mechanism and note substantial variation in how services are defined and delivered (mounted activities, groundwork, simulated devices). Early‑phase, outcomes‑oriented research predominates and reviewers recommend attention to foundational research, treatment theory, and standardized protocols in future trials.

inv-02: Evidence synthesis placed here as background context for clinical findings (duplicate grouping for writer reference)

Background evidence relevant to clinical findings (context for prior authorization or documentation requests):

Study protocols and dosage reported in trials: Some trials and reviews describe specific protocols (for example, 45‑minute sessions once‑weekly for 8–10 weeks) and report outcome measures (GMFM, Berg Balance Scale, TUG, spasticity scales, and quality‑of‑life instruments); these parameters are commonly cited when describing interventions and planning future RCTs.

See Whalen & Case‑Smith (chunk 24) and De Guindos‑Sanchez (chunk 35) for protocol examples and outcomes; pilot PTSD study reports 8‑week programs (chunk 55).

Implications for documentation and authorization: Given heterogeneity and limited certainty, prior authorization (when required by a plan) may request diagnosis, baseline and planned outcome measures, GMFCS level for children with CP, specific session frequency/duration, total planned number of sessions, and documentation of prior trials of conventional therapies when applicable.

Policy History & Review Dates

Policy Summary

PayerAetna

PolicyHippotherapy (Equine Therapy) — Clinical Policy Bulletin

Policy CodePolicy 0151

Change TypeNo material changes noted

Effective DateN/A

Next Review DateN/A

Key ActionDo not bill HCPCS S8940 for the listed indications; ensure coding aligns with plan-specific coverage and documentation if requesting authorization.

SourceLink

On This Page

No PA language present in multiple evidence summaries — check employer/plan benefits
CPB does not replace plan-specific coverage determinations

Prior Authorization

Prior authorization advisable when evidence is limited

Prior authorization advisable when evidence is limited: For indications where systematic reviews conclude evidence is limited, heterogeneous, or low/very-low certainty (e.g., CP, MS, ABI, dementia, ADHD, ASD, idiopathic scoliosis), prior authorization is advisable so the plan can review clinical justification, concurrent therapies, and outcome measures before services are initiated.

Indications with limited/low-quality evidence: cerebral palsy, multiple sclerosis, acquired brain injury, dementia, ADHD, autism, idiopathic scoliosis
Consider PA to review medical necessity and potential alternative therapies

Prior Authorization

Prior authorization — administrative note

Prior authorization: Specific PA requirements are determined by the member’s plan/benefit document. Clinical policy bulletins (CPBs) do not themselves authorize coverage; they are guidance documents. Providers must confirm PA rules, submit required documentation, and follow any plan-level utilization management protocols.

CPB is guidance — verify plan-specific PA rules
Follow plan submission requirements for PA

Denial Risk

Coding-based denial risk

Coding-based denial risk: Use of HCPCS S8940 (Equestrian/hippotherapy, per session) and listed ICD‑10 codes for excluded indications may lead to claim denial if billed without prior verification of coverage. Ensure codes used align with plan-covered services and the CPB’s not-covered lists to mitigate denial risk.

HCPCS S8940 identified as not covered for indications listed in CPB
Verify ICD‑10 code mapping to supported indications before billing
Document medical necessity if an uncommon billed indication is used

Note

Weak evidence may impact coverage decisions

Weak evidence may impact coverage: Systematic reviews and authoritative summaries note that evidence for hippotherapy is often weak, heterogeneous, or very low quality. Coverage determinations may reflect the limited evidence base; consider providing higher-quality supporting documentation when requesting coverage.

UpToDate and multiple systematic reviews characterize evidence as weak or low-certainty
Provide higher-level evidence or rationale when requesting coverage for uncommon indications

Denial Risk

Insufficient evidence may trigger noncoverage

Insufficient evidence may trigger noncoverage: For several indications (e.g., ABI, dementia, some behavioral disorders), systematic reviews report insufficient or inconsistent benefit; these findings may lead to noncoverage determinations absent compelling, patient‑specific justification.

Document why standard therapies are unsuitable or inadequate
Provide objective outcome measures and prior treatment history to support exception requests

Note

No explicit authorization or billing requirements in evidence summaries

No explicit authorization or billing requirements: Multiple evidence summaries and trials describe protocols and outcomes but do not specify authorization or billing procedures. Providers must not assume absence of PA — confirm with the payer.

Study reports typically omit billing/PA statements
Verify payer PA and billing rules before initiating therapy

Documentation Required

Coding and documentation alignment

Coding and documentation alignment: Align procedural coding and diagnostic coding with clinical documentation and CPB lists. If services are billed using non-covered HCPCS or diagnosis codes listed in the CPB, include explicit justification and supporting clinical documentation to reduce risk of denial.

Ensure HCPCS/CPT and ICD‑10 selected match documented clinical indication
Include documentation of concurrent therapies and functional limitations

Documentation Required

Required session / protocol details to document

Required session/protocol details: Trials commonly specify session parameters that should be included in authorization or medical records to substantiate the therapy (e.g., 45‑minute sessions once weekly for 8–10 weeks; 12 weeks of therapy; number of sessions and frequency).

Record session length, frequency, total number of sessions, start/end dates
Specify whether real-horse or simulator-based therapy was used

Documentation Required

Outcome measurement and documentation used in trials

Outcome measurement and documentation used in trials: Common outcome measures used in studies include Gross Motor Function Measure (GMFM-66/88), Berg Balance Scale (BBS), Timed Up and Go (TUG), Modified Ashworth Scale (MAS), Multiple Sclerosis QOL-54 (MSQOL-54), fatigue scales (FSS/MFIS), MMMS, and standardized behavioral/QOL scales. Include baseline and post-treatment scores when available.

List and report validated measures used (GMFM, BBS, TUG, MSQOL-54, FSS/MFIS, MMMS)
Provide baseline and post-intervention scores and clinician interpretation

Documentation Required