Latest Review Date: October 2024

Category:  Therapy                                                                

POLICY:

Sensory stimulation (coma stimulation) for the treatment of coma and/or persistent vegetative state is considered investigational.

DESCRIPTION OF PROCEDURE OR SERVICE:

Sensory stimulation is intended to enhance the rehabilitative potential of brain-injured individuals in a coma or vegetative state. Protocols may involve stimulation of any or all of the following senses: visual, auditory, olfactory, gustatory, cutaneous and kinesthetic. Various stimuli may be used for each sense. Protocols may differ with respect to who performs the stimulation and where. Professionals providing this service may include nurses, occupational therapists, physical therapists, and speech-language therapists. In some cases, family members may be trained in the techniques and are given primary responsibility for providing the therapy. Treatment may be delivered in the hospital, the patient's home, or a nursing home. It has been proposed that comatose individuals treated with intense and repeated stimulation following very precise protocols could awaken earlier from coma and return to a higher level of functioning.

KEY POINTS:

This evidence has been updated with a literature review using the MEDLINE database.  The most recent literature review was performed through October 9, 2024.

Summary of Evidence

Studies reviewed include systematic reviews and one RCT of sensory stimulation of individuals in coma, vegetative state and following a traumatic brain injury. Studies were reviewed and revealed the overall methodology was poor and the studies differed in design and conduct. None of the studies reviewed provided useful and valid results on the outcomes of clinical relevance for these individuals Results suggest that sensory stimulation programs may not be sufficient to restore consciousness. SSP might nevertheless lead to improved behavioral responsiveness in MCS individuals.  Our results show higher CRS-R total scores when treatment is applied, and more exactly, increased arousal and or motor functions. Given the lack of rigorous, clinically meaningful studies for inclusion and the qualitative methodological approach that was used in analysis, more research is needed to confirm the effectiveness of this treatment modality. The evidence is insufficient to determine that the technology results in an improvement in the net health outcomes.

Practice Guidelines and Position Statements

The American Occupational Therapy Association (AOTA)

According to the American Occupational Therapy Association (AOTA) updated 2016 guideline “Recommendations for Occupational Therapy Interventions for Adults with TBI”, recommendations were made specific to “Interventions to Improve Arousal and Alertness of People in a Coma or Persistent Vegetative State”. The guideline noted the following:

• Multimodal sensory stimulation to improve arousal and enhance clinical outcomes. (A)
• Auditory stimulation, especially when completed in a familiar voice, to increase arousal in the short term. (B)
• Increased complexity, rather than intensity, of stimulation to increase intervention effectiveness. (C)
• Median nerve stimulation to improve arousal and alertness. (I)

Strength of Recommendation:

1. There is strong evidence that occupational therapy practitioners should routinely provide the intervention to eligible clients. Good evidence was found that the intervention improves important outcomes and concludes that benefits substantially outweigh harm.
2. There is moderate evidence that occupational therapy practitioners should routinely provide the intervention to eligible clients. There is high certainty that the net benefit is moderate, or there is moderate certainty that the net benefit is moderate to substantial.
3. There is weak evidence that the intervention can improve outcomes. It is recommended that the intervention be provided selectively on the basis of professional judgement and patient preferences. There is at least moderate certainty that the net benefit is small.
4. There is insufficient evidence to determine whether or not occupational therapy practitioners should be routinely providing the intervention. Evidence that the intervention is effective is lacking, of poor quality, or conflicting and the balance of benefits and harm cannot be determined.

American Academy of Neurology

2018 Practice Guideline Update: Disorders of Consciousness

Recommendation 12: Complication rates are high in individuals with prolonged disorders of consciousness (DoC) and negatively affect morbidity and mortality. It is important that clinicians remain vigilant to medical complications in the short term to facilitate their early identification and to help optimize outcomes over the long term. The most common complications observed in individuals with prolonged DoC include agitation/aggression, hypertonia, sleep disturbance, and urinary tract infections. Other, more severe, complications such as hydrocephalus, pneumonia, and paroxysmal sympathetic hyperactivity can disrupt rehabilitation efforts, as they often require rehospitalization. Strategies for early detection and rapid management of complications include daily physician rounds, 24-hour specialty physician coverage, on-site availability of diagnostic resources, and timely access to specialty consultations.

U.S. Preventive Services Task Force Recommendations

Not applicable.

KEY WORDS:

Sensory stimulation, coma stimulation, vegetative state, traumatic brain injury, coma stimulation sessions, coma arousal therapy, multisensory stimulation programs, coma care

APPROVED BY GOVERNING BODIES:

Not applicable.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts: Special benefit consideration may apply.  Refer to member’s benefit plan.  

CURRENT CODING: 

CPT Codes:

HCPCS:

REFERENCES:

1. American Academy of Neurology. Practice Guideline Update: Disorders of Consciousness. Neurology. 2018. www.aan.com/Guidelines/home/GetGuidelineContent/929
2. American Academy of Neurology. Practice Parameters: Assessment and Management of Patients in the Persistent Vegetative State (Summary Statement). Report of the quality Standards Subcommittee of the American Academy of Neurology. Neurology. 1994; 45(5):1015-1018. www.aan.com/Guidelines/home/GetGuidelineContent/83. 
3. American Academy of Neurology. Practice Guideline Update: Disorders of Consciousness. American Academy of Neurology. Neurology. 2008.
4. Centers for Disease Control and Prevention (CDC): Facts About TBI. Traumatic Brain Injury & Concussion. Published 2024.  www.cdc.gov/traumatic-brain-injury/data-research/facts-stats/index.html. 
5. Çevik K, Namik E. Effect of auditory stimulation on the level of consciousness in comatose patients admitted to the intensive care unit: A randomized controlled trial. J Neurosci Nurs. 2018; 50(6):375–80.
6. Cheng et al. Do Sensory Stimulation Programs Have an Impact on Consciousness Recovery? Front Neurol. 2018 Oct 2;9:826.
7. Davis AE and Gimenez A.  Cognitive-behavioral recovery in comatose patients following auditory sensory stimulation.  J Neurosci Nurs, August 2003; 35(4): 202-9, 214.
8. Eapen BC, Georgekutty J, Subbarao B, et al. Disorders of Consciousness. Phys Med Rehabil Clin N Am. 2017; 28(2):245-58.
9. Giacino JT, Katz DI, et al. Practice guideline update recommendations summary: Disorders of consciousness: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research. Neurology. 2018 Sep 4;91(10):450-460. Erratum in: Neurology. 2019 Jul 16; 93(3): 135.
10. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
11. Karma D and Rawat AK.  Effect of stimulation in coma.  Indian Pediatrics, October 2006, Vol. 43, pp. 856-860.
12. Li J. Et al. Sensory stimulation to improve arousal in comatose patients after traumatic brain injury: a systematic review of the literature. Neurol Sci 2020 Sep; 41(9):2367-2376.
13. Lippert-Gruner M, Wedekind C and Klug N.  Outcome of prolonged coma following severe traumatic brain injury.  Brain Inj, January 2003; 17(1): 49-54.
14. Lombardi F, Taricco M, De Tanti A, et al.  Sensory stimulation of brain-injured individuals in coma or vegetative state:  Results of a Cochrane systematic review.  Clin Rehabil, August 2002; 16(5): 464-72.
15. Megha M, Harpreet S, Nayeem Z. Effect of frequency of multimodal coma stimulation on the consciousness levels of traumatic brain injury comatose patients. Brain Inj. 2013; 27(5):570-577.
16. Meyer MJ, Megyesi J, Meythaler J, et al. Acute management of acquired brain injury Part III: an evidence-based review of interventions used to promote arousal from coma. Brain Inj. 2010; b24(5):722-729.
17. Moattari M, Alizadeh Shirazi F, Sharifi N, Zareh N. Effects of a Sensory Stimulation by Nurses and Families on Level of Cognitive Function, and Basic Cognitive Sensory Recovery of Comatose Patients With Severe Traumatic Brain Injury: A Randomized Control Trial. Trauma Mon. 2016 Apr 25;21(4):e23531.
18. National Institute of Neurological Disorders and Stroke.  Traumatic brain injury:  Hope through research, catalog.ninds.nih.gov/sites/default/files/publications/traumatic-brain-injury-hope-through-research_1.pdf.
19. Padilla R, Domina A. Effectiveness of sensory stimulation to improve arousal and alertness of people in a coma or persistent vegetative state after traumatic brain injury: A systematic review. Am J Occup Ther. 2016; 70(3):1-8.
20. Pape et al. Placebo-Controlled Trial of Familiar Auditory Sensory Training for Acute Severe Traumatic Brain Injury: A Preliminary Report. Neurorehabil Neural Repair. 2015 Jul;29(6):537-47.
21. Salmani, Mohammadi, Rezvani, Kazemnezhad. The effects of family-centered affective stimulation on brain-injured comatose patients' level of consciousness: A randomized controlled trial. Int J Nurs Stud. 2017; 74:44-52.
22. Wheeler S, and A Acord-Vira. Occupational therapy practice guidelines for adults with traumatic brain injury. Bethesda (MD): American Occupational Therapy Association, Inc. (AOTA). 2016; 47 p.

POLICY HISTORY:

Medical Policy Group, September 2003 (1)

Medical Policy Administration Committee, September 2003

Available for comment November 3-December 17, 2003

Medical Policy Group, September 2005 (1)

Medical Policy Group, September 2007 (1)

Medical Policy Group, September 2009 (1)

Medical Policy Group, March 2012: Effective March 12, 2012 Policy no longer scheduled for regular literature reviews and updates.

Medical Policy Group, August 2019 (3): 2019 Updates to Key Points. A peer reviewed literature analysis was completed and no new information was identified that would alter the coverage statement of this policy.

Medical Policy Group, December 2020 (6): Updates to Key Points, Key Words (traumatic brain injury, coma stimulation sessions, coma arousal therapy, multisensory stimulation programs, coma care), USPSTF, Practice Guidelines and References. No change in policy intent.

Medical Policy Group, December 2021 (3): 2021 Updates to Key Points, Practice Guidelines and Position Statements, and References. Reviewed by consensus. No new published peer-reviewed literature available that would alter the coverage statement in this policy. Policy statement updated to remove “not medically necessary.” No other changes to policy statement or intent.

Medical Policy Group, October 2022 (3): 2022 Updates Key Points and References. Reviewed by consensus. No new published peer-reviewed literature available that would alter the coverage statement in this policy.

Medical Policy Group, October 2023 (6): Updates to Policy title: Sensory Stimulation for Brain-Injured Individuals in Coma or Vegetative State, Description, Key Points, Benefit Application, Practice Guidelines and References.

Medical Policy Group, October 2024 (9): Updates to Key Points and References. Reviewed by consensus. No new published peer-reviewed literature available that would alter the coverage statement in this policy.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.