Prior approval

Not applicable.

Investigational — denial risk

Sensory integration therapy (SIT) and auditory integration therapy (AIT) are considered investigational for all indications. Claims for SIT or AIT may be denied as investigational when submitted for reimbursement.

Prior authorization expectations

Prior authorization is not applicable for this policy; however, providers should verify member benefits and any contract exclusions at the time of service. When prior authorization is required by the member's benefit plan, documentation must include the diagnosis, prior and concurrent therapies tried, the proposed intervention details (therapy type, frequency, duration), and rationale for therapy.

• Document diagnosis and relevant ICD code(s)
• Describe prior and concurrent therapies and responses
• Provide proposed intervention details: therapy modality (SIT or AIT), session frequency, number of sessions, planned duration, and treating provider credentials

Coding accuracy required

Use appropriate CPT, HCPCS, revenue, and ICD-10 diagnosis codes and ensure billed CPT codes accurately reflect services rendered. When reporting sensory integrative techniques, use CPT 97533 (Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct one-to-one patient contact, each 15 minutes). If using CPT 97533 for AIT, document how the service meets the code description.

• CPT: 97533 — Sensory integrative techniques, per 15 minutes (may be used for auditory integration therapy when description matches)
• Ensure CPT entries match services rendered and provider documentation

Required documentation to support effectiveness

To support claims of effectiveness, include objective outcome measures, documentation of treatment fidelity (adherence to sensory integration principles if claiming SIT), and follow-up of at least six months when available. Report functional outcomes and quality-of-life measures and specify assessment tools used. For investigational therapies, provide evidence of clinical improvement and rationale for continued therapy.

• Objective outcome measures (functional scales, adaptive behavior assessments)
• Fidelity details demonstrating adherence to the intervention model
• Follow-up data with at least 6 months of outcomes reporting

Comparators / usual care

Usual-care comparators in trials include standard/established therapies such as developmentally appropriate interventions and other specialized outpatient treatments (for example, occupational therapy, behavioral therapies). Providers should document prior use of these standard interventions where relevant.

• Usual care: developmentally appropriate specialized interventions, occupational therapy, behavioral interventions

Step therapy considerations

Consideration should be given to attempting standard care or less-intensive sensory-based interventions before pursuing SIT/AIT. Documentation should show that standard or less-intensive interventions were tried, the duration and response, and clinical justification for escalation to SIT/AIT.

• Document trial of standard care or less-intensive sensory-based interventions and outcomes before initiating SIT/AIT

Preferred therapies before integration approaches

Before initiating sensory integration or auditory integration approaches, providers should prioritize established interventions with stronger evidence of benefit — for example, occupational therapy (including evidence-based OT approaches), behavioral therapies, and disorder-specific developmental interventions. Discuss the limited and inconclusive evidence for SIT/AIT with caregivers and document informed decision-making.

• Preferred initial therapies: occupational therapy, behavioral therapies, disorder-specific developmental interventions
• Discuss evidence limitations and document informed consent/decision-making

Miscellaneous provider action

Retained for completeness.